Rome-ESCMIDcourse Dec2011 Basic Hygiene & Contact … · Basic hygiene measures UPCI University of Geneva Hospitals 20 TransmissionTransmission--based precautions based precautions

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)

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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


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TRANSMISSION

Nosocomialflora

Transmission of nosocomial infections

contact

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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



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TRANSMISSION

Host defenses

Nosocomialflora

droplet


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Droplet Respiratorydroplets> 5 µm

Droplets are deposited on mucous membranes;close contact <1m for transmission

Neisseria meningitidisInfluenza virus


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TRANSMISSION

Host defenses

Nosocomialflora

airborne

Mycobacteriumtuberculosis


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Droplet Respiratorydroplets> 5 µm

Droplets are deposited on mucous membranes;close contact <1m for transmission

Neisseria meningitidisInfluenza virus


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

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common vehicle

TRANSMISSION

Host defenses

Nosocomialflora


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Strategies for infection control

Specific measuresSpecifically targeted against VAPSpecifically targeted against SSISpecifically targeted against BSI

Antibiotic controlRestriction of use, guidelines, rotation



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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

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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

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Basic hygiene measures

Standard precautionsDaily work

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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

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DROPLET

Transmission-basedprecautions

exceptions

Standard precautionsdaily work

Influenza

tuberculosis ESBL

Basic hygiene measures

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TransmissionTransmission--based precautionsbased precautionsCONTACTCONTACT

single roomor cohorting

gowngloves

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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)

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TransmissionTransmission--based precautionsbased precautionsDROPLETDROPLET

- mask when <1meter- for every patient transfer

single roomor cohorting

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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.



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TransmissionTransmission--based precautionsbased precautionsAIRBORNEAIRBORNE

- high-filtration mask - for every patient transfer

- special track for garbage- (terminal cleansing)

single room mandatory

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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

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TransmissionTransmission--based precautionsbased precautionsPROTECTIONPROTECTION

gownmask

single room mandatory

high-filtration maskfor every transfer

HCW: flu shot mandatory

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TransmissionTransmission--based precautionsbased precautionsSTRICTSTRICT

According to specificguidelines

single room MANDATORY

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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



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University of Geneva Hospitals

31

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Information easy to access !

… and what about screening for MDR microorganisms?

« Ever give a talk on MDRO screening? »

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35 UPCIUniversity of Geneva Hospitals

36

Patient X, transferred from Lybia…



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… 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%

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Lemmen S et al. J Hosp Infect 2004; 56: 191 Courtesy: A. Widmer, Basel



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

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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


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




• 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



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



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!

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Rome-ESCMIDcourse Dec2011 Basic Hygiene & Contact … · Basic hygiene measures UPCI University of Geneva Hospitals 20 TransmissionTransmission--based precautions based precautions