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EVIDENCE-BASED PREVENTION
OF HOSPITAL-ACQUIRED
AND VENTILATOR-ASSOCIATED
PNEUMONIA
Dennis G. Maki, MD University of Wisconsin School of Medicine
and Public Health
94th Annual Meeting of the AATS – Minneapolis – May 5, 2013
EVIDENCE-BASED PREVENTION
OF HOSPITAL-ACQUIRED
AND VENTILATOR-ASSOCIATED
PNEUMONIA
Dennis G. Maki, MD Division of Infectious Diseases
Department of Medicine
Center for Trauma and Life Support
University of Wisconsin
Hospital & Clinics
Madison, Wisconsin U.S.A.
FINANCIAL CONFLICTS OF INTEREST:
None
PREVENTION OF
HAP AND VAP
GOALS: To Understand 1. The nature of nosocomial infections in modern-
day ICUs in the early 21st Century and their
impact
2. The epidemiology and pathogenesis of these
infections, especially HAP/VAP
3. Control measures for prevention of HAP and VAP
4. New technologies for prevention of VAP,
nosocomial Legionella pneumonia and invasive
Aspergillus infection in the ICU
PROFILE OF NOSOCOMIAL INFECTION IN CRITICAL CARE
UNITS CONTRASTED WITH NON-ICU PATIENT CARE UNITS
• Overall rates 3- to 5-fold higher
PROFILE OF NOSOCOMIAL INFECTION IN CRITICAL CARE
UNITS CONTRASTED WITH NON-ICU PATIENT CARE UNITS
• Overall rate 3- to 5-fold higher
• Much higher rates: 1° Bacteremia
Pneumonia
PROFILE OF NOSOCOMIAL INFECTION IN CRITICAL CARE
UNITS CONTRASTED WITH NON-ICU PATIENT CARE UNITS
• Overall rate 3- to 5-fold higher
• Much higher rates: 1° Bacteremia Pneumonia
PROFILE OF NOSOCOMIAL INFECTION IN CRITICAL CARE
UNITS CONTRASTED WITH NON-ICU PATIENT CARE UNITS
• Overall rate 3- to 5-fold higher • Much higher rates:
1° Bacteremia Pneumonia
• Many more infections with ANTIBIOTIC-RESISTANT ORGANISMS
Methicillin-Resistant S. aureus, Coag-neg staphylococci Multi-resistant gram-negative bacilli Candida
TRENDS IN ANTIMICROBIAL
RESISTANCE IN U.S. ICUs
0
10
20
30
40
50
60
Percen
t resi
sta
nce
1989 1993 1997 2002 2004
year
S.aureus (methicillin)
Enterococcus (vancomycin)
K.pneumoniae(Ceph 3rd)
P.aeruginosa (Fluoroquinolones)
HOSPITAL-ACQUIRED
PNEUMONIA
• ~1% risk to hospitalized patients,
~10-fold increased risk if
mechanically ventilated
• Attributable mortality ~ 25%
• Incremental costs ~ $50,000/case
• ~100,000 cases/ year
in U.S. centers, ~30,000 deaths
PREVENTION OF HAP AND VAP
TRENDS IN DEVICE-ASSOCIATED HCAIs
1992 -- 2008 IN THE NNIS-NHSN U.S.
TEACHING HOSPITAL MED-SURG ICUs
per 1000 device-days 1992-98
CLABSIs 6.0
VAP 11.0
CAUTI 6.5
ICHE 2000
THE TRAIN HAS LEFT THE STATION
EVIDENCE-BASED GUIDELINES
TRENDS IN DEVICE-ASSOCIATED HCAIs
1992 -- 2008 IN THE NNIS-NHSN U.S.
TEACHING HOSPITAL MED-SURG ICUs
per 1000 device-days 1992-98 1995-2003
CLABSIs 6.0 4.9
VAP 11.0 4.9
CAUTI 6.5 4.9
ICHE 2000 AJIC 2003
TRENDS IN DEVICE-ASSOCIATED HCAIs
1992 -- 2008 IN THE NNIS-NHSN U.S.
TEACHING HOSPITAL MED-SURG ICUs
per 1000 device-days 1992-98 1995-2003 2007-8
CLABSIs 6.0 4.9 1.5
VAP 11.0 4.9 2.3
CAUTI 6.5 4.9 2.9
ICHE 2000 AJIC 2003 AJIC 2008
SUCCESSFUL IMPLEMENTATION OF
A VAP BUNDLE TO PREVENT VAPs
• Bonello et al. Jt Comm J Qual Patient Saf. 2008;34:639-45.
• Westwell. Nurs Crit Care. 2008;13:203-7.
• Unahalekhaka et al. Jt Comm J Qual Patient Saf. 2007;33:387-94.
• Cocanour et al. J Trauma. 2006;61:122-9.
• Burger et al. Mayo Clin Proc. 2006;81:849-50.
AN AXIOM OF CLINICAL
INFECTIOUS DISEASE
That is Highly Relevent to
HAP/VAP
Preventive strategies are most likely to be effective if based on a full understanding of pathogenesis and epidemiology.
EPIDEMIOLOGY OF NOSOCOMIAL
INFECTION
EPIDEMIOLOGIC MECHANISMS OF
ACQUISITION OF NOSOCOMIAL
INFECTION CONTACT(HCW hands)
Enteric GNB
Pseudomonads
S. aureus / MRSA
Coag-neg Staph
Enterococcus
RSV
Rotaviruses
SARS virus(?)
Mites
Lice
AIR
M. tuberculosis
Aspergillus
VZV
Influenza virus
Measles, mumps viruses
SARS virus
WATER
Legionella
Pseudomonads
HCW CARRIERS
S. aureus / MRSA
Coag-neg Staph
Gr A Streptococci
Acinetobacter
Proteus mirabilis
Citrobacter
Salmonella
HBV, HSV, HIV
EPIDEMIOLOGIC MECHANISMS OF
ACQUISITION OF NOSOCOMIAL
INFECTION CONTACT(HCW hands)
Enteric GNB Pseudomonads S. aureus / MRSA Coag-neg Staph Enterococcus/VRE Acinetobacter C. difficile RSV Rotaviruses SARS virus(?) Mites Lice
AIR
M. tuberculosis
Aspergillus
VZV
Influenza virus
Measles, mumps viruses
SARS virus
WATER
Legionella
Pseudomonads
HCW CARRIERS
S. aureus / MRSA
Coag-neg Staph
Gr A Streptococci
Acinetobacter
Proteus mirabilis
Citrobacter
Salmonella
HBV, HSV, HIV
EPIDEMIOLOGIC MECHANISMS OF
ACQUISITION OF NOSOCOMIAL
INFECTION CONTACT(HCW hands)
Enteric GNB
Pseudomonads
S. aureus / MRSA
Coag-neg Staph
Enterococcus
RSV
Rotaviruses
SARS virus(?)
Mites
Lice
AIR
M. tuberculosis
Aspergillus
VZV
Influenza virus
Measles, mumps viruses
SARS virus
WATER
Legionella
Pseudomonads
HCW CARRIERS
S. aureus / MRSA
Coag-neg Staph
Gr A Streptococci
Acinetobacter
Proteus mirabilis
Citrobacter
Salmonella
HBV, HSV, HIV
EPIDEMIOLOGIC MECHANISMS OF
ACQUISITION OF NOSOCOMIAL
INFECTION CONTACT(HCW hands)
Enteric GNB
Pseudomonads
S. aureus / MRSA
Coag-neg Staph
Enterococcus
RSV
Rotaviruses
SARS virus(?)
Mites
Lice
AIR
M. tuberculosis
Aspergillus
VZV
Influenza virus
Measles, mumps viruses
SARS virus
WATER
Legionella
Pseudomonads
HCW CARRIERS
S. aureus / MRSA
Coag-neg Staph
Gr A Streptococci
Acinetobacter
Proteus mirabilis
Citrobacter
Salmonella
HBV, HSV, HIV
EIDEMIOLOGY AND PATHOGENESIS OF
HAP, VAP AND HCAP
Crnich, Safdar and Maki. Resp Ther (2005)
PATHOGENESIS OF VENTILATOR-
ASSOCIATED PNEUMONIA
• Pooling of hypophayngeal secretions above
the ETT cuff (and aspiration around the cuff)
Pathogenesis of VAP
Stomach
Oropharynx
Trachea
Ventilator-Associated Pneumonia
Exogenous
Sources
Endogenous
Sources
Microbiology of VAP NNIS, Crit Care Med 1999; 27(5): 887-92 [N = 4,389]
PREVENTION OF HAP-VAP
•Hand Hygiene…preemptive barrier precautions
•Noninvasive ventilation
•Protocolized weaning
•Semi-recumbent positioning
•Ventilation Circuit Management
•Heat Moisture Exchangers
•Selective (antimicrobial) digestive decontamination (SDD)
•Oral care with CHG
•Novel endotracheal tubes
•Prevention of Legionella infection
•Prevention of invasive Aspergillus infection
PREVENTION OF
NOSOCOMIAL PNEUMONIA
•Hand Hygiene
HAND HYGIENE
• Transient carriage on hands of HCWs
major mode of spread of most
nosocomial pathogens
• Hand hygiene compliance rates
25-50%, at best
MICROORGANISMS CARRIED ON THE
HANDS OF ICU PERSONNEL
UNIVERSITY OF WISCONSIN HOSPITALS
All
Microorganisms
Gram-Negative
Bacilli Staph aureus
Mean Log CFU
Recovered from
persons’ hands
4.59 1.04 0.44
[Range of Individual
Means] [3.31-5.76] [0.29-1.93] [0-1.45]
Percentage all cultures
positive 100 44 11
Percentage of
individuals positive
at least once
100 100 64
Maki, Ann Intern Med 89 (Part 2):777-80 (1980)
IMMEDIATE BACTERIAL REMOVAL WITH
THREE HANDWASHING AGENTS Maki et al (1978)
Each agent studied in 10 individuals; one week between tests. Cultures
obtained immediately before (B) and after (A) handwashing with the agent
ANTISEPTIC-CONTAINING HANDWASHING
AGENTS REDUCE NOSOCOMIAL INFECTIONS A PROSPECTIVE STUDY IN A SICU
Nongermicidal
Soap
Povidone-Iodine 4% Chlorhexidine
No. Patients 36 37 39
Infections (%):
Urinary tract 13 (36.1) 7 (18.9)* 10 (25.6)
Respiratory 16 (44.4) 15 (40.6) 7 (17.9)+
Surgical Wound 2 (5.6) 1 (2.70) 2 (5.1)
Bacteremia 1 (2.8) 3 (8.1) 2 (5.1)
Overall 33 (91.7) 27 (72.9)* 20 (51.3)+
Rate per 10,000 ICU
Days
_________________
957 692* 645+
957
*P < .05, +P < .01. Maki et al (1980)
STUDY OF HANDWASHING AGENTS ON
RATE OF NOSOCOMIAL INFECTION
Prospective study: Chlorhexidine group (Hibiclens®)
Lotion soap (Kindest Kare®)
Lotion soap + alcohol rinse (Calstat®)
Three agents used in alternating cycles in 3 ICUs over 8 months
Rates nosocomial infection lowest with chlorhexidine:
40 NI/1000 patients
vs.
52 NI/1000 patients
Higher volume of chlorhexidine used by personnel (P<.001)
All three agents tolerated comparably by users.
OR 0.73
P = 0.01
Doebbeling et al, N Engl J Med 327:88 (92)
CDC HICPAC Hand Hygiene
Recommendations • Use an alcohol-
based hand rub: – Before and after
direct contact with patients or their environment (includes equipment)
– Before performing invasive procedures
Hands should be washed with antiseptic
and water after contact with patients with
diarrhea or known C. difficile +
Project to
~450-750,000
cases/yr
in U.S
McFarland et al. Curr Opinion GE 2008
Zilberberg et al. ICHE 2009
INCIDENCE AND
TRENDS CDAD
IN U.S. POPULATION
THE NEEDFOR A NEW PARADIGM
FOR NOSOCOMIAL INFECTION CONTROL
• Large, multicenter RCT(s) of waterless alcohol handrubs vs conventional handwashing with CHG
PREVENTION OF
NOSOCOMIAL PNEUMONIA
•Hand Hygiene…preemptive barrier isolation precautions
0
10
20
30
40
50
60
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
Perc
en
t R
esis
tan
ce
Non-ICU ICU
MRSA in U.S. Hospitals: National
Nosocomial Infections Surveillance
(NNIS) System Report
VRE in U.S. Hospitals: National
Nosocomial Infections Surveillance
(NNIS) System Report
0
5
10
15
20
25
30
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
Perc
en
t R
esis
tan
ce
Non-ICU ICU
The Iceberg of Resistance Safdar and Maki (2003)
23% 21% 39% 29%
(2134) (1622) (381) (314)
MRSA VRE ESBL+
Gram-negative
Bacilli
C. difficile
No. of patients developing nosocomial infection
/ No. of colonized patients (%)
Pathogen Studies Overall General
inpatients
Immuno-
compromised ICU patients
MRSA 17 409/1708 (24) 106/734 (14) 34/205 (17) 269/769 (35)
VRE 20 531/2862 (19) 433/2248 (19) 51/389 (13) 54/293 (18)
Resistant
GNRSi
9 217/873 (25) 59/359 (16) 15/71 (21) 143/443 (32)
C. difficile 5 30/380 (8) 30/380 (8) NA NA
Safdar and Maki (2004)
PROSPECTIVE STUDIES OF THE RISK OF
INFECTION FOLLOWING COLONIZATION
BY MULTIRESISTANT NOSOCOMIAL
PATHOGENS
STRATEGIES FOR CONTROLLING
SPREAD OF RESISTANT ORGANISMS,
VIEWING THE “ICEBERG” PRINCIPLE
1. MICROBIOLOGIC SURVEILLANCE, ie for
MRSA or VRE, WITH TARGETED
PRECAUTIONS ONLY FOR CARRIERS
PROSPECTIVE STUDIES OF MICROBIOLOGIC SURVEILLANCE
WITH TARGETED PRECAUTIONS TO CONTROL NOSOCOMIAL
INFECTION WITH MULTIRESISTANT PATHOGENS
Author, year Organism Outbreak Outcome Effect
Thompson et al, 1982 MRSA yes successful C/I 33 to 6/mo
Walsh et al, 1987 MRSA yes successful C >2 to <1/mo
Murray-Leisure et al, 1990 MRSA yes successful C/I 16 to <3/mo
Handwerger et al, 1993 VRE yes successful outbreak eradicated
Boyce et al, 1994 VRE yes successful outbreak eradicated
Wells et al, 1995 VRE yes unsuccessful controlled, not eradicated
Morris et al, 1995 VRE no unsuccessful no change in endemic rates of
VRE
Jernigan et al, 1996 MRSA yes successful C from 0.14 to 0.009
cases/day
Back et al, 1996 MRSA yes successful outbreak eradicated
Girou et al, 1998 MRSA no successful C/I 5.8% to 2.6%
Goetz et al, 1998 VRE yes unsuccessful outbreak persisted
Brown et al, 1998 VRE yes successful outbreak eradicated
Lai et al, 1998 VRE yes unsuccessful controlled, not eradicated
Montecalvo et al, 1999 VRE yes unsuccessful outbreak persisted, isolation of
all high risk patients necessary
to contain spread
Jochimsen et al, 1999 VRE yes unsuccessful outbreak persisted
Byers et al, 2001 VRE yes successful C/I
Ostrowsky et al, 2001 VRE yes successful C from 2.2% to 0.,5%
Siddiqui et al, 2002 VRE no successful C/I from 11.4 to 7.7 per 10,000
patient-days
STRATEGIES FOR CONTROLLING
SPREAD OF RESISTANT ORGANISMS,
VIEWING THE “ICEBERG” PRINCIPLE
1. MICROBIOLOGIC SURVEILLANCE, ie for
MRSA or VRE, WITH TARGETED
PRECAUTIONS ONLY FOR CARRIERS
However:
Screening is expensive
STRATEGIES FOR CONTROLLING
SPREAD OF RESISTANT ORGANISMS,
VIEWING THE “ICEBERG” PRINCIPLE
1. MICROBIOLOGIC SURVEILLANCE, ie for MRSA or VRE, WITH TARGETED PRECAUTIONS ONLY FOR CARRIERS
However:
Screening is expensive
24-48 hour delay
STRATEGIES FOR CONTROLLING
SPREAD OF RESISTANT ORGANISMS,
VIEWING THE “ICEBERG” PRINCIPLE
1. MICROBIOLOGIC SURVEILLANCE, ie for MRSA or VRE, WITH TARGETED PRECAUTIONS ONLY FOR CARRIERS
However:
Screening is expensive
24-48 hour delay in getting results
It has to be repeated 5-7 days
STRATEGIES FOR CONTROLLING
SPREAD OF RESISTANT ORGANISMS,
VIEWING THE “ICEBERG” PRINCIPLE
1. MICROBIOLOGIC SURVEILLANCE, ie for MRSA or VRE, WITH TARGETED PRECAUTIONS ONLY FOR CARRIERS
However:
Screening is expensive
24-48 hour delay in getting results
It has to be repeated every 5-7 days
It only addresses 1 pathogen
THE STAR-ICU TRIAL • A multi-center, cluster-randomized trial of admission
screening for MRSA-VRE and targeted isolation
vs standard ICU care
• 19 ICUs, ~10,000 patients, ~50,000 ICU patient-days
• >25% of patients MRSA or VRE positive on admission
• Outcome Measure: new MRSA or VRE colonization or infection in ICU
• RESULTS: screened 40 vs controls 34
cases/1000 ICU-days, P=0.80
Huskins et al. New Engl J Med 2009
STRATEGIES FOR CONTROLLING
SPREAD OF RESISTANT ORGANISMS,
VIEWING THE “ICEBERG” PRINCIPLE
1. MICROBIOLOGIC SURVEILLANCE, ie for MRSA or
VRE, WITH TARGETED PRECAUTIONS ONLY FOR
CARRIERS
2. PREEMPTIVE BARRIER PRECAUTIONS FOR
ALL HIGH RISK PATIENTS
PROSPECTIVE A RANDOMIZED TRIAL IN A PEDIATRIC ICU
STANDARD CARE vs PROTECTIVE ISOLATION
Variable Standard Care Isolation
No. of patients studied 38 32
Total no. of infections (per 100 days) 40 (8.6) 15 (4.4)
Definite 30 12
Probable 10 3
Mean no. of infections/patient 1.05 0.47
Mean no. of infections/patient/day 0.064 0.029
(95% confidence interval) (0.022-0.185) (0.018-0.049)*
Type of infection (no./100 days)
Lower respiratory 10 (2.1) 5 (1.5)
Upper respiratory 5 (1.1) 1 (0.3)
Urinary tract 5 (1.1) 5 (1.5)
Gastroenteritis 9 (1.9) 2 (0.6)
Skin or skin structures 7 (1.5) 2 (0.6)
Primary or secondary bacteremia 6 (1.3) 1 (0.3)§
Days with temperature >38.5°C (%) 21 13¶
*P=0.007 §P = 0.08 ¶P = 0.001 Klein, Perloff and Maki. N Engl J Med 320:1714 (89)
Intensive Care Unit Day
N Engl J Med (1989)
PREVENTION OF C. DIFFICILE INFECTION BY
PREEMPTIVE USE OF GLOVES BY HCWs
Cases C. difficile infection/1000 pt-days
Before After
Study ward 7.7 1.5*
Control wards 5.7 4.2
Johnson et al, Am J Med (92). *P = 0.01
CONTROL OF MRSA IN A BURN UNIT BY
PREEMPTIVE BARRIER PRECAUTIONS
Safdar and Maki, Am J Infect Control 2006; 34: 476-83.
STUDIES OF PREEMPTIVE BARRIER PRECAUTIONS FOR ALL
HIGH RISK PATIENTS (GOWNS AND NONSTERILE GLOVES) FOR
PREVENTION OF NOSOCOMIAL INFECTION
Author, year Organism Outbreak Outcome Effect
Agbayani et al, 1981 all no successful 86% RRR in NEC
LeClair et al, 1987 RSV no successful 65% RRR
Klein et al, 1989 all no successful 60% RRR
Johnson et al, 1990 C. difficile no successful 65% RRR
Maki et al, 1996 VRE yes successful outbreak eradication
Maki et al, 1996 MRSA yes successful outbreak eradication
Maki et al, 1996 MRSA yes successful outbreak eradication
Slaughter et al, 1996 VRE no unsuccessful no added advantage of gowns
McManus et al, 1998 GNB no successful 60% RRR
Passweg et al, 1998 all no successful 24% RRR
McCartney et al, 2000 RSV no successful 39% RRR
Koss et al, 2001 all no unsuccessful higher incidence of nosocomial pneumonia in isolation group
Slota et al, 2001 all no successful 57% RRR
PREVENTION OF
NOSOCOMIAL PNEUMONIA
•Hand Hygiene
•Noninvasive ventilation
USE OF NON-INVASIVE VENTILATION IN AN ICU
A Case-Control Study NIV
(CPAP-BiPAP)
Intubation
+ CMV
P-value
No. patients 50 50
SAPS II 35.6 37.3 NS
Age 72 yrs 70 yrs NS
PaO2 208 mm 194 mm NS
PCO2 70 mm 73 mm NS
Nosocomial infections
Any 7 (14%) 19 (38%) 0.006
Pneumonia 4 (8%) 11 (22%) 0.04
Antibiotic therapy 4 (8%) 13 (26%) 0.01
Duration ventilation 6 days 10 days 0.01
LOS ICU 9 days 15 days 0.02
Overall Mortality 2 (4%) 13 (26%) 0.002
Girou et al, JAMA 284:2361-7 (2000)
• Burke KE et al. Noninvasive positive pressure
ventilation as a weaning strategy for intubated
adults with respiratory failure. Cochrane
Database Syst Rev. 2010 Aug 4;(8).
• 12 RCTs, most in COPD
• ICU LOS -6 days
• HAP/VAP RR 0.29 (0.19-0.45) • Mortality RR 0.55 (0.38-0.79)
PREVENTION OF HAP-VAP
•Hand Hygiene
•Noninvasive ventilatio
•Protocolized weaning
PROTOCOLIZED WEANING BY
RESPIRATORY THERAPISTS
Protocolized weaning clearly reduces LOT on MV
by ~25 % and the frequency of tracheostomies
and prolonged MV, and can be assumed to
reduce the incidence of VAP.
• Blackwood B et al. Protocolized versus non-protocolized weaning
for reducing the duration of mechanical ventilation in critically ill
adult patients. Cochrane Reviews 2010
• Burns KE et al. Wean earlier and automatically with new
technology (the WEAN Study): A multicentre, pilot randomized
controlled trial. Am Rev Resp CCM 2013 Mar 22.
PREVENTION OF
NOSOCOMIAL PNEUMONIA
•Hand Hygiene
•Noninvasive ventilation
•Protocolized weaning
•Semi-recumbent positioning
RANDOMIZED TRIAL OF
SEMIRECUMBANT POSITIONING
ON THE INCIDENCE OF VAP
P = 0.003
P = 0.018
Risk Factors for VAP
Supine position: OR 6.8 (1.7 - 26.7)
Enteral feeding: OR 5.7 (1.5 - 22.8)
MV > 7 days: OR 10.9 (3.0 - 40.4)
Drakulovic et al, Lancet 1999; 354: 1851-8
PREVENTION OF
NOSOCOMIAL PNEUMONIA
•Hand Hygiene
•Noninvasive ventilation
•Protocolized weaning
•Semi-recumbent positioning
•Ventilation Circuit Management
•Heat Moisture Exchangers
Circuit Condensate
Humidified Air
vs.
Heat Moisture Exchangers
Benefit of HMEs Comparative Clinical Trials
Pooled Analysis: OR 0.61, 95% CI 0.39 - 0.94, P = 0.03
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
Kirton, Chest 1997
Hurni, Chest 1997
Dreyfuss, AJRCCM 1995
Roustan, Int Care Med
1992
Martin, Chest 1990
HME Humidified Air
Tubing changes Observational studies suggest that changes every 7 days is as safe as more frequent changes Changes >7d (i.e, no change) has been evaluated in a limited fashion
Open versus closed suctioning Closed suction systems reduce the risk of transient hypoxia and lung collapse Impact on infection is less clear with 2 studies finding no change in rates of VAP
MANAGEMENT OF THE
CIRCUIT
PREVENTION OF HAP-VAP
•Hand Hygiene
•Noninvasive ventilation
•Protocolized weaning
•Semi-recumbent positioning
•Ventilation Circuit Management
•Heat Moisture Exchangers
•Selective (antimicrobial) digestive decontamination (SDD)
Prevention of VAP and all ICU-acquired Infections by
Topically-applied Antimicrobial or Antiseptic agents: a
Meta-analysis of RCTs in ICUs
Crit Care 2011; 15(3): R155.
VAP RR 0.64, P<0.001
All NI, RR 0.71, P=0.02
No impact ICU mortality
PREVENTION OF
NOSOCOMIAL PNEUMONIA
•Hand Hygiene
•Noninvasive ventilation
•Protocolized weaning
•Semi-recumbent positioning
•Ventilation Circuit Management
•Heat Moisture Exchangers
•Oral care with CHG
ANTISEPTIC CHG ORAL CARE IN THE ICU
IMPACT OF SCHEDULED ORAL CARE IN
ICU WITH CHLORHEXIDINE
A Meta-analysis
• 7 prospective RCTs.
• Reduced VAP,
RR, 0.74 (0.56-0.96), P=.02.
• Greatest benefit in CV surgery,
• RR, 0.41 (0.17-0.98Z), P=.04.
• No mortality benefit
Cheblicki and Safdar, Crit Care Med. 2007;35(2):595-602
Vernon et al. Arch Intern Med 166:306-12, 2006
A NOVEL APPROACH TO CONTAINING RESISTANCE
Cleansing Patients with CHG Daily
A NOVEL APPROACH TO
PREVENTING IVD-RELATED BS Cleansing Patients with CHG Daily
Prospective cross-over trial on 4 medical units at
Cook County Stroeger Medical Center
Compared daily CHG sponge bath vs nonmedicated soap bath (control)
Results, daily CHG bath:
CVC-associated BSI RR 0.40, P<0.01
MRSA BSI RR 0.0, P<0.01
Bleasdale, Weinstein et al, Arch Intern Med 2007; 167:2073-2079
MRSA IS THE
800 POUND GORILLA
OF SSI
MRSA is the cause of 10-20% SSIs
In USA, 100-200,000 MRSA cases
annually
IMPACT OF MRSA vs MSSA
SURGICAL SITE INFECTIONS
MRSA vs MSSA
Excess Mortality Extra
LOS OR Costs
• Engelmann et al. 5 d 3.4 $40,000
CID 2003
• Anderson et al. 35 d 7.3 $62,000
PLOS One 2009
Vernon et al. Arch Intern Med 166:306-12, 2006
A NOVEL APPROACH TO CONTAINING RESISTANCE
Cleansing Patients with CHG Daily
THE ONLY RCT OF CULTURE SCREENING AND
DECOLONIZATION FOR PREVENTION OF STAPH
AUREUS SSI
THE ONLY RCT OF CULTURE SCREENING AND
DECOLONIZATION FOR PREVENTION OF STAPH
AUREUS SSI
There were no MRSA SSIs
PROSPECTIVE TIME-SEQUENCE STUDIES OF
PREOPERATIVE MRSA SCREENING WITH
DECOLONIZATION PRIOR TO SURGERY
Type of Surgery
Study
Nasal
Mupirocin
Skin
Antisepsis
Std
Screen+
Decoln
RR
P-Value
Cardiovascular
Currier et al.
JHI 2002
√ CHG 0.41 0.02
0,10 <.01
Schlenz et al.
JHI 2005
√ CHG 2.6 1.5 0.53 <0.02
Jag et al.
JHI 2008
Walsh et al.
Arch IM 2010
√
√
CHG
CHG
1.15
1.15
0.26
0.07
0.23
0.07
<0.01
<0.01
MRSA SSI (%)
PROSPECTIVE TIME-SEQUENCE STUDIES OF
PREOPERATIVE MRSA SCREENING WITH
DECOLONIZATION PRIOR TO SURGERY
Type of Surgery
Study
Nasal
Mupirocin
Skin
Antisepsis
Std
Screen+
Decoln
RR
P-Value
Orthopoedic
Nixom et al.
JBJS 2006
All Types
Harbarth
JAMA 2008
√
√
CHG
CHG
0.45
0.53
0.19
0.63
0.38
1.10
<0.001
NS
Robicsec et al.
Ann IM 2008
√ CHG 2.83 1.63 0.52 <0.001
Pofahl et al..
JACS 2008
√
CHG
0.23
0.09
0.24
<0.01
MRSA SSI (%)
PREVENTION OF HAP-VAP
•Hand Hygiene
•Noninvasive ventilation
•Protocolized weaning
•Semi-recumbent positioning
•Ventilation Circuit Management
•Heat Moisture Exchangers
•Oral care with CHG
•Selective (antimicrobial) digestive decontamination (SDD)
•Novel endotracheal tubes
Continuous aspiration of
subglottic secretions
SUBGLOTTIC SUCTIONING—A META-ANALYSIS
Dezfulian et al Am J Med 2005; 18
PATHOGENESIS OF VAP ROLE OF BIOFILM
MULTISPECIES BIOFILM AGGREGATES ON LUMINAL SURFACE OF AN
ENDOTRACHEAL TUBE IN A MECHANICALLY VENTILATED PATIENT
Costerton et al J. Clin. Invest. 112:1466-1477 (2003)
MULTICENTER RANDOMIZED TRIAL OF A SILVER-
COATED ENDOTRACHEAL TUBE FOR PREVENTION
OF VENTILATOR-ASSOCIATED PNEUMONIA
Control
ETT
Silver-
coated
ETT
RR
P-Value
No. patients studied 964 968
No. developing VAP
with BAL>104 cfu
56
(5.8%)
37
(3.8%)
0.66 0.03
No. adverse events
possibly related to ETT
138
(14.3%)
140
(14.5%)
0.91 0.03
Kolef et al, JAMA 300:805-13, 2008
MULTICENTER RANDOMIZED TRIAL OF A SILVER-
COATED ENDOTRACHEAL TUBE FOR PREVENTION
OF VENTILATOR-ASSOCIATED PNEUMONIA
Kolef et al, JAMA 300:805-13, 2008
ENDOTRACHEAL TUBES WITH
SUPERCOMPLIANT POLYURETHANE
CUFFS TO PREVENT MICROASPIRATION
• RCT in 134 postop CV surgery patients,
RR VAP 0.33 (0.12-0.17), P=0.01, no impact ICU LOS.
Poelaert et al. J Thorac CV Surg 2008;136:771-6.
• RCT in 140 patients in med-surg ICU,
RR VAP 0.33 (0.11-0.88), P=0.01
Lorente et al. Am J Resp CCM 2007;176:179-83.
PREVENTION OF HAP-VAP
•Hand Hygiene
•Noninvasive ventilation
•Protocolized weaning
•Semi-recumbent positioning
•Ventilation Circuit Management
•Heat Moisture Exchangers
•Oral care with CHG
•Selective (antimicrobial) digestive decontamination (SDD)
•Novel endotracheal tubes
•Antimicrobial stewardship
STRATEGIES FOR CONTROLLING ANTIBIOTIC
RESISTANCE AND SUPERINFECTION
1. ANTIMICROBIAL STEWARDSHIP
Eliminate unnecessary use
Improve quality of use
• Surveillance of resistance
• Institutional guidelines
• Limited, focused formulary
• Educational programs
• Automatic Stop-orders
• ID, Pharmacy Consultation
• Microbiology Lab policies
• Restrictions on use of key drugs
• Antibiotic “rotations”
• Audits of use
STRATEGIES FOR CONTROLLING ANTIBIOTIC
RESISTANCE AND SUPERINFECTION
1. ANTIMICROBIAL STEWARDSHIP
Eliminate unnecessary use
Improve quality of use
• Surveillance of resistance
• Institutional guidelines
• Limited, focused formulary
• Educational programs
• Automatic Stop-orders
• ID, Pharmacy Consultation
• Microbiology Lab policies
• Restrictions on use of key drugs
• Antibiotic “rotations”
• Audits of use
GUIDELINES FOR RESTRICTION
PROGRAMS: Rules of the Game • It must be efficient: 24/7,
telephone communication
• The program must never delay prompt therapy for potential lifethreatening infection: A first dose is always given on request
• Permission from a representitive of the P&T Committee is required for subsequent doses
RESTRICTED DRUGS:
“Last resort” Agents: Linezolid
Daptomycin
Tigecycline
Amikacin
Very costly drugs: L-Amphotericin B
Complex to Use or toxic: Foscarnet
Drugs restricted on epidemiologic grounds:
Vancomycin
3rd- gen cephalosporins
Imipenem
Voriconazole
RESTRICTION PROGRAMS
MARKEDLY REDUCES USAGE OF
RESTRICTED ANTIINFECTIVES
McGowan and Finland. J Infect Dis 1974;130:165-8
McGowan and Finland. South Med J 1976; 69:174-9
Craig et al. Ann Intern Med 1978;83:796-8
Recco et al. JAMA 1979;241:2283-6
Coleman et al. Am J Med 1991;90:439-44
Woodward et al. Am J Med 1987;83:817-23
Himmelberg et al. Am J Hosp Pharm 1991;48:1220-7
ANTIMICROBIAL
RESTRICTIONS: PRO
1. Global crisis in antibiotic resistance
2. Resistance = excess mortality,
3. Antimicrobial pressure drives resistance
4. Restrictions highly effective at limiting unnecessary use
5. Implementation of restrictions has been followed by greatly reduced usage of restricted antimicrobials
and reductions in rates of resistance.
6. “The needs of the many outweigh the needs of the few”
RESTRICTIONS OF KEY ANTIMICROBIALS HAVE
BEEN FOLLOWED BY REDUCED INFECTIONS
BY IN TARGETED RESISTANT PATHOGENS-1
• Macrolide-resistant Group A Streptococci
Seppela et al, N Engl J Med 1997
• Penicillin-resistant Strep pneumoniae
Stephenson et al. JAMA 1996
• VRE Quale et al. Clin Infect Dis 1996
Bradley et al. JAC 1999
May et al. Shock 2000
• Clostridium difficile
O’Connor et al. Quart J Med 2002
Wilcox et al.JAC 2002
RESTRICTIONS OF KEY ANTIMICROBIALS HAVE
BEEN FOLLOWED BY REDUCED INFECTIONS
BY IN TARGETED RESISTANT PATHOGENS-1
• MRSA
Landeman et al. Clin Infect Dis 1999
• ESBL-positive resistant GNRs
Rahal et al. JAMA 1998
Landeman et al. Clin Infect Dis 1999
Singh et al. Am J Resp Crit Care Med 2000
Carling et al. Infect Control Hosp Epidemiol 2003
Rice et al. Clin Infect Dis 1996
White et al. Clin Infect Dis 1997
Lan et al. J Microbiol Immunol 2003
• Piperacillin-tazobactam-resistant P aeruginosa
Allegranzi et al. J Hosp Infect 2002
ANTIMICROBIAL
RESTRICTIONS: PRO
1. Global crisis in antibiotic resistance
2. Resistance = excess mortality,
3. Antimicrobial pressure drives resistance
4. Restrictions are highly effective at limiting unnecessary use ….and provide a unique opportunity for real-time education
5. Restrictions = reductions in resistance.
6. “The needs of the many outweigh the needs of the few”
PREDICTION: MORE
RELIABLE, RAPID (MOLECULAR)
DIAGNOSTICS WILL SOON
GREATLY REDUCE
UNNECESSARY ANTIMICROBIAL
THERAPY.
PREVENTION OF HAP-VAP
•Hand Hygiene
•Noninvasive ventilation
•Protocolized weaning
•Semi-recumbent positioning
•Ventilation Circuit Management
•Heat Moisture Exchangers
•Oral care with CHG
•Selective (antimicrobial) digestive decontamination (SDD)
•Novel endotracheal tubes
•Antimicrobial Stewardship
•Prevention of invasive Aspergillus infection
Recirculating
Portable HEPA
Filtration Device
THE VALUE OF ASPERGILLUS-FREE AIR IN THE
CARE OF BONE MARROW TRANSPLANT PATIENTS
Control Period without
HEPA-Filtration
HEPA Air
Filtration+
Mean CFU/M3 Aspergillus
fumigatus 2.1 .2
P < .001
No. Bone Marrow
Transplant Patients 67 187
No. developing invasive
Aspergillus infection 12 (18%) 9 (5%)
P < .01 +Portable HEPA unit in each room. Rhame et al, Am J Med (1984)
50%
43%
29%
0%
Construction
PERCENTAGE OF LEUKEMIA PATIENTS
ACQUIRING
NOSOCOMIAL ASPERGILLOSIS
No HEPA No HEPA;
Antibiotics
HEPA Overflow to
nonHEPA
(6/12)
(12/28)
(0/26)
(13/45)
Oren, I, et.al. 2001
HOSPITAL RENOVATION
The Problem
HOSPITAL RENOVATION
The Problem - 1
• 1998-99: costs of new hospital construction up 28.5%
• In 1998, 75% of new construction was renovation of existant facilities or creation of new contiguous facilities
• OPD facility construction up 17%
McKee (1998), Croswell, Modern Healthcare (1999)
HOSPITAL RENOVATION
The Problem - 2
• Construction, renovation or demolition generates vast quantities of dust which contains huge numbers of aerosolized filamentous fungi, such as Aspergillus, and sometimes as other potential pathogens, such as Legionella. Moreover, construction can impair air handling systems or contaminate potable water with these pathogens.
EPIDEMIOLOGIC MECHANISMS OF
NOSOCOMIAL INFECTION CONTACT
Enteric GNB Pseudomonads S. aureus / MRSA Coag-neg Staph Enterococcus HBV RSV Rotaviruses RSV SARS virus Mites Lice
AIR
M. tuberculosis
Aspergillus,
other fungi VZV
Influenza virus
Measles, mumps viruses
SARS virus
WATER
Legionella
Pseudomonads
HCW CARRIERS
S. aureus / MRSA
Coag-neg Staph
Gr A Streptococci
Acinetobacter
Proteus mirabilis
Citrobacter
Salmonella
HBV, HSV, HIV
ASPERGILLUS FUMIGATUS
VanCutsem, et. al. 1984
• Most common cause of invasive
and non-invasive aspergillosis
• Causes >50% of invasive
aspergillosis
• Capable of growth up to 55°C
(131°F)
EPIDEMIOLOGY
• A. fumigatus is a ubiquitous organism whose primary ecological niche is felt to be decomposing vegetable matter.
• Ambient levels in outside air is considerable
– Typical 1-15 spores/m3 with significant day to day variability.
– May reach tremendous levels near compost heaps and hay barns (106 spores/m3).
HOSPITAL RENOVATION
The Problem - 3
• Hospitals and clinics are filled with
patients who are immunocompromised
and highly vulnerable to devastating
invasive infection with these newly
unleashed pathogens
Aspergillus - Vulnerable Patient
Exposure
Invasive Pulmonary Aspergillosis Fungal Research Trust
Invasive Aspergillosis - Pulmonary Infarction Fungal Research Trust
Pegues, D. et. al. Clin Infect Diseases, 2002 34:412-6
Lutz, et. al., Clin Infect Dis 37: 786-793, 2003
6 ASPERGILLUS SSI TRACED TO
PROCEDURES IN 12-DAY PERIOD
INVASIVE ASPERGILLOSIS
• Caused by extremely common mold.
• Spread through air easily.
• Can be difficult to diagnose in severely immunosuppressed patients.
• Mortality over 50%.
Prevention of Exposure is Key
PATIENTS AT RISK • Bone marrow transplant patients
• Hematology and oncology patients who develop severe and prolonged neutropenia
• Solid organ transplant patients (intestinal > lung > liver > heart > kidney)
• Patients who receive prolonged high-dose corticosteroids (~1 mg/kg >1 week)
Recirculating
Portable HEPA
Filtration Device
THE VALUE OF ASPERGILLUS-FREE AIR IN THE
CARE OF BONE MARROW TRANSPLANT PATIENTS
Control Period without
HEPA-Filtration
HEPA Air
Filtration+
Mean CFU/M3 Aspergillus
fumigatus 2.1 .2
P < .001
No. Bone Marrow
Transplant Patients 67 187
No. developing invasive
Aspergillus infection 12 (18%) 9 (5%)
P < .01 +Portable HEPA unit in each room. Rhame et al, Am J Med (1984)
50%
43%
29%
0%
Construction
PERCENTAGE OF LEUKEMIA PATIENTS
ACQUIRING
NOSOCOMIAL ASPERGILLOSIS
No HEPA No HEPA;
Antibiotics
HEPA Overflow to
nonHEPA
(6/12)
(12/28)
(0/26)
(13/45)
Oren, I, et.al. 2001
WHAT HAPPENS TO
PATIENTS WHO LEAVE THE
PROTECTED WARD?
Construction Phase No. Air Samples No. Positive (%) IPA Rate
(per 1,000)
A (Indoor)
27
1 (3.7)
0.73
B (Indoor) 24 4 (16.7) 0.24*
* P < 0.001
Adapted from Raad et al, Infect Control Hosp Epidemiol, 2002
EPIDEMIOLOGY OF ASPERGILLOSIS
OUTBREAKS: 1972-2003
Cause of outbreak No. studies Total no.
patients
Mean no./
Outbreak
Adjacent outdoor
construction
4 48 12
Indoor renovation 12 78 6.5
Ventilation system contamination 5 69 14
Contaminated insulation 3 23 7.5
Contaminated dressings 2 7 4
Other 5 40 8
Total 31 265 8.5
NOSOCOMIAL OUTBREAKS ASSOCIATED
WITH EXTERNAL CONSTRUCTION
Organism
No. of studies
Aspergillus species 14
Legionella species 2
Acinetobacter baumanii 1
Nocardia asteroides 1
Histoplasma capsulatum 2*
HOSPITAL
RENOVATION
The Solution
HOSPITAL RENOVATION
The Fundamental Issues in Patient
Protection
1. Isolate (shield ) the patient
2. Isolate the work area
3. Take nothing for granted, achieving maximal patient
safety is complex, takes a great deal of coordination
among many stakeholders and requires a well-oiled
systems approach, with well-defined responsibilities
and accountability.
HOSPITAL RENOVATION
Programmatic Essentials • Baseline institutional compliance + familiarity with AIA guidelines
• Comprehensive written Construction and Renovation P&P, with:
– Defined authority and responsibilities:
• To initiate construction or renovation
• For daily implementation of P&Ps
• For closure or relocation patient-care units
• Infection control risk assessment (ICRA)
Dust Generating Risk
(A - D)
Patient Area Risk
(Minimal – High)
Infection Control
Precautions
Level (I - IV)
Pre-Construction IC Risk Assessment
UWHC Policy 13.16
HOSPITAL RENOVATION
Programmatic Essentials • Baseline institutional compliance + familiarity with AIA guidelines
• Comprehensive written Construction and Renovation P&P, with:
– Defined authority and responsibilities:
• To initiate construction or renovation
• For daily implementation of P&Ps
• For closure or relocation patient-care units
Pre-Construction IC
Authorization
UWHC Policy 13.16
Nurse manager – notified of project and risk, signature required before work can begin
Infection Control Practitioner – Initial check of worksite precautions; signature required before work can begin.
Work crew – Maintenance of day to day containment of worksite; completion of Daily Worksite Checklist by supervisor required.
Level II, III, IV
Level III, IV
Level III, IV
HOSPITAL RENOVATION
Programmatic Essentials • Baseline institutional compliance + familiarity with AIA guidelines
• Comprehensive written Construction and Renovation P&P, with:
– Defined authority and responsibilities:
• To initiate construction or renovation
• For daily implementation of P&Ps
• For closure or relocation patient-care units
– ICRA, monthly review by ICC
– Relocate high-risk patients and units
– Procedures for HVAC/air handling, dust and debris, and water control
– Contractor and institutional responsibilities and accountability
– Education of HCWs and contractors – Transport and disposal of waste materials
– Monitoring of compliance with P&Ps, criteria for halting work,
check-off list desireable
– Traffic patterns for patients, HCWs and construction workers
– Emergency preparedness (ie, water leaks, HVAC failure,
– Air or water environmental sampling
• Infection control risk assessment (ICRA)
• Implementation (and revision) of the program on an ongoing basis
TRAINING STICKER
A small sticker (about 2" diameter) which we give to contractors to affix to their hardhats after
they have completed Safety/Infection Control Training. It enables us to see, at a glance, who has
been trained at the worksite.
HOSPITAL RENOVATION
Programmatic Essentials • Baseline institutional compliance + familiarity with AIA guidelines
• Comprehensive written Construction and Renovation P&P, with:
– Defined authority and responsibilities:
• To initiate construction or renovation
• For daily implementation of P&Ps
• For closure or relocation patient-care units
– ICRA, monthly review by ICC
– Relocate high-risk patients and units
– Procedures for HVAC/air handling, dust and debris, and water control
– Contractor and institutional responsibilities and accountability
– Education of HCWs and contractors
– Transport and disposal of waste materials
– Monitoring of compliance with P&Ps, criteria for halting work,
check-off list desireable
– Traffic patterns for patients, HCWs and construction workers
– N95 masks for high-risk patients leaving protected unit – Emergency preparedness (ie, water leaks, HVAC failure,
– Air or water environmental sampling
• Infection control risk assessment (ICRA)
• Implementation (and revision) of the program on an ongoing basis
HOSPITAL RENOVATION
Programmatic Essentials • Baseline institutional compliance + familiarity with AIA guidelines
• Comprehensive written Construction and Renovation P&P, with:
– Defined authority and responsibilities:
• To initiate construction or renovation
• For daily implementation of P&Ps
• For closure or relocation patient-care units
– ICRA, monthly review by ICC
– Relocate high-risk patients and units
– Procedures for HVAC/air handling, dust and debris, and water control
– Contractor and institutional responsibilities and accountability
– Education of HCWs and contractors
– Transport and disposal of waste materials
– Monitoring of compliance with P&Ps, criteria for halting work,
check-off list desireable
– Traffic patterns for patients, HCWs and construction workers
– N95 masks for high-risk patients leaving protected unit
– Emergency preparedness (ie, water leaks, HVAC failure,
– Air or water environmental sampling
• Infection control risk assessment (ICRA)
• Implementation (and revision) of the program on an ongoing basis
HOSPITAL RENOVATION Procedures
for HVAC/Air Handling, Dust Abatement- 1
• Barrier systems:
– Fire-rated plastic sheeting, sealed at ceiling height
vs.
Rigid,dust-proof, fire-resistant rigid walls, with caulked seams, entry vestibule, gasketed door frames
– Sealed windows in patient-care units, assure HEPAs functional and not leaking, rooms + units of high-risk patients positive-pressure, inlet air filters functional, signage
• Negative-pressure work area:
– Outlet air to building exterior or HEPA-filtered if recirculated, scavenging HEPA filters in work areas, no disruption of hospital HVAC/air flow patterns, monitor pressures/air flow patterns frequently, avoid overloading air ducts
– Designated worker traffic routes, waste egress
• Planning for disruption of utility services
• Worker risk assessment and education
• Heightened surveillance for related infection
HOSPITAL RENOVATION Procedures
for HVAC/Air Handling, Dust Abatement- 1
• Barrier systems:
– Fire-rated plastic sheeting, sealed at ceiling height
vs.
Rigid,dust-proof, fire-resistant rigid walls, with caulked seams, entry vestibule, gasketed door frames
– Sealed windows in patient-care units, assure HEPAs functional and not leaking, rooms + units of high-risk patients positive-pressure, inlet air filters functional, signage
• Negative-pressure work area:
– Outlet air to building exterior or HEPA-filtered if recirculated, scavenging HEPA filters in work areas, no disruption of hospital HVAC/air flow patterns, monitor pressures/air flow patterns frequently, avoid overloading air ducts
– Designated worker traffic routes, waste egress
• Planning for disruption of utility services
• Worker risk assessment and education
• Heightened surveillance for related infection
HOSPITAL RENOVATION Procedures
for HVAC/Air Handling, Dust Abatement- 1
• Barrier systems:
– Fire-rated plastic sheeting, sealed at ceiling height
vs.
Rigid,dust-proof, fire-resistant rigid walls, with caulked seams, entry vestibule, gasketed door frames
– Sealed windows in patient-care units, assure HEPAs functional and not leaking, rooms + units of high-risk patients positive-pressure, inlet air filters functional, signage
• Negative-pressure work area:
– Outlet air to building exterior or HEPA-filtered if recirculated, scavenging HEPA filters in work areas, no disruption of hospital HVAC/air flow patterns, monitor pressures/air flow patterns frequently, avoid overloading air ducts
– Designated worker traffic routes, waste egress
• Planning for disruption of utility services
• Worker risk assessment and education
• Heightened surveillance for related infection
HOSPITAL RENOVATION Procedures
for HVAC/Air Handling, Dust Abatement- 1
• Barrier systems:
– Fire-rated plastic sheeting, sealed at ceiling height
vs.
Rigid,dust-proof, fire-resistant rigid walls, with caulked seams, entry vestibule, gasketed door frames
– Sealed windows in patient-care units, assure HEPAs functional and not leaking, rooms + units of high-risk patients positive-pressure, inlet air filters functional, signage
• Negative-pressure work area:
– Outlet air to building exterior or HEPA-filtered if recirculated, scavenging HEPA filters in work areas, no disruption of hospital HVAC/air flow patterns, monitor pressures/air flow patterns frequently, avoid overloading air ducts
– Designated worker traffic routes, waste egress
• Planning for disruption of utility services
• Worker risk assessment and education
• Heightened surveillance for related infection
When is a HEPA filter
not
a HEPA filter?
HOSPITAL RENOVATION Procedures
for HVAC/Air Handling, Dust Abatement- 1
• Barrier systems:
– Fire-rated plastic sheeting, sealed at ceiling height
vs.
Rigid,dust-proof, fire-resistant rigid walls, with caulked seams, entry vestibule, gasketed door frames
– Sealed windows in patient-care units, assure HEPAs functional and not leaking, rooms + units of high-risk patients positive-pressure,
inlet air filters functional, signage • Negative-pressure work area:
– Outlet air to building exterior or HEPA-filtered if recirculated, scavenging HEPA filters in work areas, no disruption of hospital HVAC/air flow patterns, monitor pressures/air flow patterns frequently, avoid overloading air ducts
– Designated worker traffic routes, waste egress
• Planning for disruption of utility services
• Worker risk assessment and education
• Heightened surveillance for related infection
CONSTRUCTION SIGNAGE
HOSPITAL RENOVATION Procedures
for HVAC/Air Handling, Dust Abatement- 1
• Barrier systems:
– Fire-rated plastic sheeting, sealed at ceiling height
vs.
Rigid,dust-proof, fire-resistant rigid walls, with caulked seams, entry vestibule, gasketed door frames
– Sealed windows in patient-care units, assure HEPAs functional and not leaking, rooms + units of high-risk patients positive-pressure, inlet air filters functional, signage
• Negative-pressure work area:
– Outlet air to building exterior or HEPA-filtered if recirculated, scavenging HEPA filters in work areas, no disruption of hospital HVAC/air flow patterns, monitor pressures/air flow patterns frequently, avoid overloading air ducts
– Designated worker traffic routes, waste egress
• Planning for disruption of utility services
• Worker risk assessment and education
• Heightened surveillance for related infection
Vent to
outside
Filter and
Recirculat
e
Filtered exhaust
may be ducted:
• Directly to outside of building
• Outside via exhaust duct
• Into areas surrounding construction site
OUTSIDE EXHAUST
HOSPITAL RENOVATION Procedures
for HVAC/Air Handling, Dust Abatement- 1
• Barrier systems:
– Fire-rated plastic sheeting, sealed at ceiling height
vs.
Rigid,dust-proof, fire-resistant rigid walls, with caulked seams, entry vestibule, gasketed door frames
– Sealed windows in patient-care units, assure HEPAs functional and not leaking, rooms + units of high-risk patients positive-pressure,
inlet air filters functional, signage • Negative-pressure work area:
– Outlet air to building exterior or HEPA-filtered if recirculated,
scavenging HEPA filters in work areas, no disruption of hospital HVAC/air flow patterns, monitor pressures/air flow patterns frequently, avoid overloading air ducts
– Designated worker traffic routes, waste egress
• Planning for disruption of utility services
• Worker risk assessment and education
• Heightened surveillance for related infection
Recirculating
HEPA for
Dilution
Ventilation
HOSPITAL RENOVATION Procedures
for HVAC/Air Handling, Dust Abatement- 1
• Barrier systems:
– Fire-rated plastic sheeting, sealed at ceiling height
vs.
Rigid,dust-proof, fire-resistant rigid walls, with caulked seams, entry vestibule, gasketed door frames
– Sealed windows in patient-care units, assure HEPAs functional and not leaking, rooms + units of high-risk patients positive-pressure, inlet air filters functional
• Negative-pressure work area:
– Outlet air to building exterior or HEPA-filtered if recirculated, scavenging HEPA filters in work areas, no disruption of hospital
HVAC/air flow patterns, monitor pressures/air flow patterns frequently, avoid overloading air ducts
– Designated worker traffic routes, waste egress
• Planning for disruption of utility services
• Worker risk assessment and education
• Heightened surveillance for related infection
EXHAUST DUCT
Exhaust grilles
(e.g., bathrooms)
OUT
OUT
EXHAUST INTO DUCT
OUT
AVOID OVERPRESSURIZING
EXHAUST DUCTS
ONLY UWHC HVAC
personnel permitted to
access ducts.
AIR SAMPLING DURING CONSTRUCTION: SOLID
ORGAN TRANSPLANT UNIT
AIR SAMPLING DURING CONSTRUCTION:
PEDIATRIC HEMATOLOGY-ONCOLOGY UNIT
HOSPITAL RENOVATION Procedures
for HVAC/Air Handling, Dust and Debris Control - 2
• Remediation after water contamination:
– Define full extent of contamination, assess interstitial spaces,
underneath carpeting, behind cabinets…moisture meters
helpful
– Seal area, maintain negative-pressure…mobile HEPAs
– Decontaminate with chlorine-based mist or diluted bleach vs
1:9 copper-8-quinolinate fungicide
– Remove contaminated materials ASAP, <24 hrs
– Vacuum sealings with HEPA vacuum cleaner
HOSPITAL
RENOVATION
Take-home Message
HOSPITAL
RENOVATION
Take Home Message
• Get involved early in renovation planning.
• Train facility Plant Engineering workers and outside contractors.
• Establish routes for workers/ trash removal to minimize impact on patient care areas.
• Do not begin work until risk assessment complete and authorization obtained.
HOSPITAL RENOVATION
Take Home Message
• Establish and maintain negative pressure at worksite.
• Visquene or durable barriers, taped at edges; may
need to extend through interstitial.
– May need input from Safety Officer
• Barriers/neg pressure must remain until all dust generating work is complete, walls and ceilings closed, sanding done, area cleaned.
HOSPITAL RENOVATION
Take Home Message
• Filter worksite air if recirculated
• Lightly spray down carpets before removal.
• Bag or cover trash before leaving worksite. Wipe down carts if visibly soiled.
• May need recirculating HEPAs in adjoining patient areas.
PREVENTION OF HAP-VAP
•Hand Hygiene
•Noninvasive ventilation
•Protocolized weaning
•Semi-recumbent positioning
•Ventilation Circuit Management
•Heat Moisture Exchangers
•Oral care with CHG
•Selective (antimicrobial) digestive decontamination (SDD)
•Continuous subglottic suctioning
•Silver-coated endotracheal tubes
•Prevention of invasive Aspergillus infection
•Prevention of nosocomial Legionella infection
CONTROL OF NOSOCOMIAL
LEGIONELLOSIS AT THE UNIVERSITY OF
WISCONSIN HOSPITAL AND CLINICS
• In 1987 we had 2 cases of nosocomial
Legionella pneumonias over 4 months,
sent our water out for Legionella
culturing and it was negative
CONTROL OF NOSOCOMIAL
LEGIONELLOSIS AT THE UNIVERSITY OF
WISCONSIN HOSPITAL AND CLINICS
• In 1987 we had a case of nosocomial Legionella pneumonias over 4 months, sent our water out for sampling and it was negative
• In 1993 we had another small cluster (2 cases) and did large-volume sampling and PFEP subtyping of 8 nosocomial isolates since 1985 ourselves.
Maki, Marx and Stolz. ICAAC 2007
CONTROL OF NOSOCOMIAL
LEGIONELLOSIS AT THE UNIVERSITY OF
WISCONSIN HOSPITAL AND CLINICS
• In 1987 we had a case of nosocomial Legionella pneumonias over 4 months, sent our water out for sampling and it was negative
• In 1993 we had another small cluster (2 cases) and did large-volume sampling and PFEP subtyping of 8 nosocomial isolates since 1985
ourselves: 39% of water samples were +, with very low numbers of organisms(<100 cfu/L), all 8 isolates over 11 years were clonal with our water strains.
Maki, Marx and Stolz. ICAAC 2007
CONTROL OF NOSOCOMIAL
LEGIONELLOSIS AT THE UNIVERSITY OF
WISCONSIN HOSPITAL AND CLINICS
• In 1987 we had a case of nosocomial Legionella pneumonias over 4 months, sent our water out for sampling and it was negative
• In 1993 we had another small cluster (2 cases) and did large-volume sampling and PFEP subtyping of 8 nosocomial isolates since 1985 ourselves: 39% of water samples were +, with very low numbers of organisms(<100 cfu/L), all 8 isolates over 11 years were clonal with our
water strains. We attempted pulse hyperchlorination.
Maki, Marx and Stolz. ICAAC 2007
COPPER-SILVER IONIZATION
CONTROL OF NOSOCOMIAL
LEGIONELLOSIS AT THE UNIVERSITY OF
WISCONSIN HOSPITAL AND CLINICS
• In 1987 we had a case of nosocomial Legionella pneumonias over 4 months, sent our water out for sampling and it was negative
• In 1993 we had a small cluster (2 cases) and did large-volume sampling and PFEP subtyping of 8 nosocomial isolates since 1985 ourselves: 39% of water samples were +, with very low numbers of organisms(<100 cfu/L), all 8 isolates over 11 years were clonal with our water strains. We attempted pulse hyperchlorination.
• In 1995, we implemented continuous silver-copper ionization of our hospital water:
1985-1995 ~210,000 admissions 10 cases nLD
Maki, Marx and Stolz. ICAAC 2007
CONTROL OF NOSOCOMIAL
LEGIONELLOSIS AT THE UNIVERSITY OF
WISCONSIN HOSPITAL AND CLINICS
• In 1987 we had a case of nosocomial Legionella pneumonias over 4 months, sent our water out for sampling and it was negative
• In 1993 we had a small cluster (2 cases) and did large-volume sampling and PFEP subtyping of 8 nosocomial isolates since 1985 ourselves: 39% of water samples were +, with very low numbers of organisms(<100 cfu/L), all 8 isolates over 11 years were clonal with our water strains. We attempted pulse hyperchlorination.
• In 1995, we implemented continuous silver-copper ionization of our hospital water:
1985-1995 ~210,000 admissions 10 cases nLD 1995-2012 ~325,000 admissions 0 cases nLD
Maki, Marx and Stolz. ICAAC 2007
PREVENTION OF
NOSOCOMIAL PNEUMONIA
•Hand Hygiene
•Noninvasive ventilation
•Semi-recumbent positioning
•Ventilation Circuit Management
•Heat Moisture Exchangers
•Oral care with CHG
•Continuous subglottic suctioning
•Silver-coated endotracheal tubes
•Prevention of invasive Aspergillus infection
•Surveillance of VAP with feedback and benchmarking