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BACTERIA TO BED BUGS: INFECTION CONTROL UPDATE
Dawn Tomac RN, CIC
Director of Quality
Avera Health
Bed Bugs to Bad BugsAround since the 17th centuryS ll ( l d i )Small (apple seed size)Oval, flattened shapeBrown-redNocturnalFeed on humansSome will display symptoms and others will not
http://ohioline.osu.edu/hyg-fact/2000/2105.html
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HistoryIn medieval times bed bugs preferred the rich as they had the warmest homesthey had the warmest homesIt eventually became a problem for all classesUntil World War II • DDT• Vacuums
Gl b li iGlobalization• Hotels, hospitals, college dorms, airports, and homes
Bed BugsFound in dwellings with high occupant turn overF l b d b l f t t l Female bed bugs lay from one to twelve eggs per day. Egg to adult takes 21 daysNymphs and adults can live several months without food.Need blood meal to molt.Adult lifespan is 12-18 months
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Bed bugsPrefer fabric, wood and paper. Can be found around tufts and seams of Can be found around tufts and seams of mattressesThey can hide in window and door frames, baseboards, furniture, and moreBed bugs are not known to transmit diseaseInfestations are best handled by licensed pest Infestations are best handled by licensed pest management professionalAdult bed bugs can crawl 4 feet per minutehttp://ipm.ifas.ufl.edu/resources/grants_showcase/people_and_communities/bed_bugs_manual.pdf
Look at the seams.
http://nysipm.cornell.edu/publications/bed_bugs/files/bed_bug.pdf
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Bed bugsRed, often with darker red spot in middleItchyItchyArrange in a rough line or in a clusterLocated face, neck, arms and handsRarely on trunk-scabies is usually palms, soles, between the toes and fingershttp://www.mayoclinic.com/health/bedbugs/DS00663/DSECTION=symptoms
Bed bugsMore a nuisance than medical threat.Spread slowly by themselvesSpread slowly by themselvesInspect your hotel room focusing on the bedClean and get rid of clutterRepair furniturehttp://nysipm.cornell.edu/publications/bed_bugs/files/bed_bug.pdf
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Sanitation MeasuresFrequent vacuuming – check every bed seam and tuft, bed frame, upholstered furniture, draperies, base boards, carpet next to base board and cracks in furnitureLaundering of bedding and clothing • 140 degree hot dryer for 20 minutes• Steam Cleaning• Extreme heat or freezingVacuum every day• Tilt mattress and box spring and furniture upside down to reach all
sides.• Seal vacuum cleaner bag in sealed plastic bag. Place bag in freezer
f 24 h th di f itfor 24 hours, then dispose of it.Bed bugs crawl they do not fly or jump. • Make your bed an island• Bed skirts and linens off the floor• Caulking and barriers on bed legs.
SanitationLess toxic types of products now available• Can become resistant to the types of products used• Can become resistant to the types of products used• Silica gel dusts
Used in wall voids
• Contact your extension office
Stiff brush can be used to clean mattress seams. Repair cracks in plaster and glue down wall paperRepair cracks in plaster and glue down wall paper
Cornell University: Bed Bugs are back! An IPM answer, 2003
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Questions?
http://www.ca.uky.edu/entomology/entfacts/ef636.asp
MRSA
Around since the 1960’sH lth A i dHealthcare AcquiredCommunity AcquiredSpread by direct contactEvidence of resistance in animals
http://phil.cdc.gov/phil/quicksearch.asp
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Community
MRSAHealthcare
Different then Health care acquiredNo healthcare stay within last 2 years.Risk Factors
Associated with stay in hospital or nursing homeRisk factors• Multiple
hospitalizations• IV drug use, sports
teams, incarceration, military service
hospitalizations• Renal failure• LTC stay• Frequent Antibiotics
MRSA - transmission
Usually spread by physical contact• Hands• Wounds
Do not share personal items
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MRSA Survival
14 days on Formica surfaces6 to 8 weeks on cotton-blanket materialPolyester: up to 40 daysPolyethylene: > 51 daysS. aureus remains virulent for at
least 10 days after exposure to y pdry surfaces
VREFound in fecesMajority of them will be E. faeciumMajority of them will be E. faeciumThese organisms can cause UTI’s, biliary infections, intra-abdominal infections, and bacterial endocarditisWide spread vancomycin use increases the incidence of VREPatients admitted to a room of a previous VRE patient are at increase risk of acquiring the bacteria.
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Up to 41% of HCW’s hands sampled (after patient care and before hand hygiene)
VRE From Hands and EnvironmentVRE From Hands and Environment
1 week to 2 months on countertops7 days to 4 months on dry polyvinyl chloride surfaces1 day to > 3 months on cloth and plastic surfaces
Noskin GA et al. ICHE 1995; 16:577Bonilla HA et al. ICHE 1996; 17:770Wendt C et al. J Clin Micro 1998; 36:1998Neely AN et al. J Clin Micro 2000; 38:724Noskin GA et al. AJIC 2000; 28:311
Inanimate Environment Can Facilitate Transmission
Hayden M, ICAAC, 2001, Chicago, IL.X represents VRE culture positive sites
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Acinetobacter baumanniiDefined as multidrug resistance to more than two of the following five drug classes:of the following five drug classes:
Antipseudomonal cephalosporin's (ceftazidime or Cefepime)Antipseudomonal carbapenems (imipenem or meropenem)Ampicillin/sulbactamFluoroquinolones (ciprofloxacin or levofloxacin)Aminoglycosides (gentamicin, tobramycin, amikacin)
Acinetobacter baumanniiCapable of surviving for extended periods of time on inanimate surfaces on inanimate surfaces.
Outbreaks occur, and/or when Acinetobacter survives due to incomplete cleaning and becomes endemic to the setting.One outbreak reported was associated with a pulsatile lavage wound therapy.50% of outbreaks a source could not be identified.
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Acinetobacter baumanniiOutbreak situations may warrant surveillance cultures of patients most at risk of six body cultures of patients most at risk of six body sites(throat, nose, skin, wounds, rectum, endotracheal aspirates)
Best practice for surveillance cultures is not available because they have not been verified to be effective.Surveillance of the environment maybe indicated in an outbreak situation. In a study of colonizing sites half of the cultures done were positive in a 5 month study. Digestive tract was a major reservoir.
Acinetobacter baumanniiTransmission is most commonly associated with contaminated skin body fluids equipment or contaminated skin, body fluids, equipment or environment.
Suction equipment, ventilators, shower trolleys, washbasins, infusion pumps, pillows and mattresses, bedrails, sinks, resuscitation equipment, bedside tables, hygroscopic bandages, and stainless steel
t carts.
Hand Hygiene is very ImportantContact Precautions with private room.
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MDRO – Gram Negative RodsMDRO-GNR(Multi-drug Resistant Gram Negative Rods) Non-ESBL: Pseudomonas Aeruginosa: Non-Rods) Non ESBL: Pseudomonas Aeruginosa: Nonsusceptible to Carbapenems (imipenem, meropenem), 3rd and 4th generation Cephalosporins (ceftazidime, cefepime), Aminoglycosides (amikacin, gentamicin, tobramycin), Fluoroquinolones (ciprofloxacin, Levaquin, gatifloxacin), Broad spectrum penicillins (Timentin, piperacillin, Tazidime, aztreonam), and Non-susceptible to all antibiotics except intermediate or sensitive to Amikacin or Aztreonam (ignore Meropenem)
Pseudomonas aeruginosa
Common cause of ventilator associated pneumoniaI h bit i t i t h t il Inhabits moist environments such as water, soil, and plantsPeople with cystic fibrosis, burn victims, and other patients in intensive care units are at riskNot a normal part of a persons flora.It can cause UTI’s, dermatitis, soft tissue infections, bacteremia and other systemic infections.
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PseudomonasIn nature it might be found as a biofilm. It loves to grow at 37 degrees but as high as 42 It loves to grow at 37 degrees but as high as 42 degrees.Only a few antibiotics are effective against Pseudomonas, including fluoroquinolones, gentamicin and imipenem. Accounts for 10 1 percent of all hospital acquired Accounts for 10.1 percent of all hospital acquired infections.
Sinks
Dec. 2004 – Mar 2006 36 patients exposed to P. gi i ICU t l t itaeruginosa in an ICU or transplant unit
17 of the infected patients died within 3 months
12 of 17 deaths P. aeruginosa contributed to or directly caused death
Source of the outbreak - hand hygiene sink drains, where biofilms containing viable organisms were foundg g
During hand hygiene contents splashed at least one meter from sink
Sink renovation
Hota S et al. ICHE 2009 30:25-33
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ESBL Producing Bacteria
Extended Spectrum Beta Lactamase An enzyme that protects the bacteria from An enzyme that protects the bacteria from antibioticsTwo Main bacteria • Klebsiella pneumoniae• Escherichia coli
• Noted in Enterobacter cloacae, P. aeruginosa, and Noted in Enterobacter cloacae, P. aeruginosa, and Serratia marcescensResistant to ceftazidime, cefotaxime, ceftriaxone, aztreonam, cefoxitin, cefotetan and meropenum and imipenem.
ESBLHave been isolated in abscesses, blood, catheter tips lung peritoneal fluid sputum and throat tips, lung, peritoneal fluid, sputum and throat culture. Generally found after treatment with cephalosporins or through nosocomial transmission. Medical use of antibiotics can accelerat the selection pressure. pIdentifying these are still a challenge.
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ESBLRisk factors for infection include ICU, recent surgery instrumentation prolonged hospital stay surgery, instrumentation, prolonged hospital stay and antibiotic exposure.
Especially to extended spectrum beta lactam antibiotics
The lower GI tract of colonized patients is the main reservoir of these organisms. This carriage can g gpersist for months. Nursing home residents can be at risk because of treatment with empiric antibiotics.
carbapenem-resistant Enterobacteriaceae
Resistant to almost all antimicrobial agentsHi h t f bidit d t litHigh rates of morbidity and mortality• Most at risk are those critically ill with ventilators and
central lines
Main bacteria involved• Klebsiella pneumoniae (most common)• E. coli
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Carbapenem Resistant EnterobacteriaceaeCarbapenem-Resistant Enterobacteriaceae (CRE) or CRKP (carbapenem-resistant Klebsiella pneumonia): KPC confers resistance to penicillins, cephalosporins, aztreonam clavulanic acid, and tazobactam, in addition to carbapenems, making treatment of these infections very challenging. This occurs most commonly in Klebsiella pneumoniae. It is also reported in Klebsiella oxytoca, Citrobacter freundii, Enterobacter spp., E.coli, Salmonella spp., and Serratia spp.
Susceptibility Profile of KPCAntimicrobial Interpretation Antimicrobial Interpretation
Amikacin I Chloramphenicol R
C fAmox/clav R Ciprofloxacin R
Ampicillin R Ertapenem R
Aztreonam R Gentamicin R
Cefazolin R Imipenem R
Cefpodoxime R Meropenem R
Cefotaxime R Pipercillin/Tazo R
Cetotetan R Tobramycin R
Cefoxitin R Trimeth/Sulfa R
Ceftazidime R Polymyxin B MIC >4μg/ml
Ceftriaxone R Colistin MIC >4μg/ml
Cefepime R Tigecycline S
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Comments: URINE CULTURE FOR POSSIBLE ESBL
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URINE CULTURE Final 08/26/11-0943
Organism 1 ENTEROBACTER CLOACAE
Colony Count >100,000 CFU/ML
MULTIDRUG RESISTANT, ORG.SENSI - WAS REPEATED. SEE TEXT/COMMENT.
ENTEROBACTER CLOACAE
This isolate has been confirmed as producing a carbapenemase (by the State Health Lab). It is resistant to all beta-lactam antimicrobials including extended spectrum cephalosporins, cefoxitin and carbapenems. There may be few antimicrobial choices. Consider Infectious Disease consult as clinically indicated. ******************************************************
ENT CLOAC M.I.C. RX ABN
Trimethoprim/Sulfamethoxazole >=320 R
Cefazolin >=64 R
Cefoxitin >=64 R
Ceftazidime >=64 R
C ft i 32 R Ceftriaxone 32 R
Cefepime 32 R
Ciprofloxacin >=4 R
Gentamicin 8 I
Imipenem >=16 R
Nitrofurantoin 128 R
Piperacillin/Tazobactam >=128 R
Levofloxacin >=8 R
CRE Infection ControlBe aggressive
Implement Contact PrecautionsImplement Contact PrecautionsMust Gown and GloveMust practice good Hand HygieneClean equipment between patients
Look for others with CRE by doing rectal cultures on those in close proximity to the index case.
If other cases found do weekly surveillance cultures on patients in same unit.
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Clostridium difficileSpore forming gram positive organism.The most common cause of antibiotic The most common cause of antibiotic associated diarrheaRequires two elements• Exposure to antibiotics• Acquisition of C. difficile by fecal oral routeRisk Factors
All tibi ti h b i li t d b t i ll • All antibiotics have been implicated but especially cephalosporins, clindamycin and fluoroquinolones
• Even single prophylactic surgical antibiotics have been implicated.
Clostridium difficileEnvironmental surfaces are readily contaminated
Bleach based disinfectants are Bleach based disinfectants are recommended in out break situations; some facilities use it for all cases.Remember to thoroughly clean surfaces such as commodes
Hand hygiene with soap and water is often an intervention
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DiagnosisDiagnosisTesting should only be done on diarrhea (unformed) stool unless ileus diarrhea (unformed) stool, unless ileus is suspected. (B-II)Testing of stool of asymptomatic patients is not clinically useful. It is only recommended in epidemiological y p gstudies (B-III)Stool culture is the most sensitive test (A-II)
Clostridium difficileIncubation is not clearly known
One study suggested short period < 7 daysOne study suggested short period < 7 days.C. difficile infection occurring with in 4 weeks of hospitalization should be attributed to being health care acquired. As long as no previous infection 8 weeks prior to admission or event.
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TreatmentTreatment
Discontinue inciting antibiotics as soon as possible (A II)(A-II)
May influence risk of CDI recurrence Severe or Complicated CDI is suspected
Initiate treatment as soon as suspectedIf stool toxin assay is negativeIf stool toxin assay is negative
Decision to stop therapy must be individualized
TreatmentTreatment
Stop antiperistaltic agents (C-III)May obscure symptomsMay precipitate toxic mega colon
Metronidaxole is drug of choice (A-I) for initial mild to moderate CDIVancomycin is drug of choice (B-I) for severe CDI
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NorovirusHighly contagious-5 billion infectious doses in each gram of feces30 million viral particles in one projectile vomiting incident10-100 viral particles = infectious dose21 million illnesses each yearHumans only known reservoirSSymptoms are diarrhea, vomiting and stomach painAnyone can get it and can occur multiple times Most common cause of gastroenteritis in US
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NorovirusNorwalk agent
Discovered in a school in Norwalk Ohio in 1968Discovered in a school in Norwalk, Ohio in 1968.Estimated 5,461,731 infections every year.14,663 Hospitalizations149 deaths a year
http://www.cdc.gov/foodborneburden/2011-foodborne-estimates.html
NorovirusDehydration is a problemContagious from the moment they feel ill till at least Contagious from the moment they feel ill till at least 3 days and as long as 2 weeksTransmitted by
Eating and drinking contaminated food and liquidsAerosolized vomitusT hi f d th l i th i h d i th i Touching surfaces and then placing their hand in their mouthsDirect contact or when sharing food, drinks
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Norovirus Gets Around QuicklyEating
Drinking
People are contagious from the moment they feel ill until 3 days after they recover
Norovirus ControlWash hands with soap and water (20 seconds)Carefully wash fruits and vegetablesCarefully wash fruits and vegetablesDo not prepare food when ill and for 3 days afterNo bare hand contact with ready to eatClean contaminated surfaces with a bleach based disinfectantWash laundry thoroughly
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Norovirus ControlExclude ill staff (food, child care, patient care workers) until 48 to 72 hours after symptom ) y presolutionIsolate ill residents until 24-48 hours after symptom resolutionClean 1:10 dilution of household bleach or premixed formulationsCollect whole stool specimens from at least 5 people in the acute phase (<72 hours)Report to health department
How long do they live?Even in the absence of visible soil with body fluids and blood there are bacteriaand blood there are bacteria
MRSA can survive for weeksClostridium difficile for yearsVRE several days to weeksNoroviruses on any hard surface for up to Noroviruses on any hard surface for up to 12 hours
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Scissors232 scissors sampled182 colonized with bacteria182 colonized with bacteriaNurses scissors and communal scissors the worstCleaning occurred infrequentlyEffective disinfection did occur by wiping scissors with an alcohol swab
Embil JM et al. ICHE, 23: 147-151
Bacterial Contamination of Hospital Physicians’ Stethoscopes
355 Stethoscopes tested234 > 2 diff t b t i l i234 > 2 different bacterial species31 carried potentially pathogenic bacteria
70% alcohol or liquid soap for membrane disinfectionNo bacteria survived after disinfection
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Mobile Phones
Patients and Visitors133 - cultured121 - positive cultures101 - Coagulase-negative Staph
42 - MRCNS
18 S aureus
HCW’s67 - cultured58 - positive cultures52 - Coagulase-negative Staph18 - S. aureus
1 - MRSA
14 - Strep spp. 4 - ESBL11 - Bacillus spp.
p21 - MRCNS
4 - S. aureus7 - Strep spp.2 – Bacillus spp.
Tekerekoglu MS. AJIC 39: 370-381
P P S
Survival of Pathogens onSurvival of Pathogens onEnvironmental SurfacesEnvironmental Surfaces
PATHOGEN PRESENCE ON SURFACES
C. difficile > 5 months
Staphylococci 7 months
VRE 4 months
Acinetobacter 5 months
Norovirus 3 weeks
Adenovirus 3 months
Rotovirus 3 months
SARS, HIV Days to week
Hota B Clinical Infectious Diseases 2004;39:1182-9
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Questions?
