Healthcare-Associated Infections and Infection Control

Timothy H. Dellit, MDMedical Director, Infection Control

Harborview Medical Center

Patient Safety and Infection Control• Prevention, monitoring, and feedback

– Healthcare-associated infections• Catheter-associated bloodstream infections• Ventilator-associated pneumonia• Surgical site infections• Catheter-associated UTI

– Transmission of multidrug-resistant/marker organisms• MRSA• VRE• Carbapenem-resistant Acinetobacter• ESBL-producing organisms → MDR Enterobacteriaceae• C. difficile• Aspergillus in burn and immunocompromised populations• Tuberculosis

Increasing Regulation and Reporting

• CMS and “preventable events”– FY2008

• Catheter-associated urinary tract infection• Vascular catheter-associated infections• Mediastinitis after CABG

– FY2009• SSI following select orthopedic procedures

– Spinal fusion– Elbow and shoulder arthroplasty

• SSI following bariatric surgery• Mandatory reporting of healthcare-associated infections (HB 1106)

– Central line infections in ICU: July 2008– Ventilator-associated pneumonia: January 2009– Selected surgical site infections: January 2010

• Cardiac surgery• Total hip and knee arthroplasty• Hysterectomy

CMS RHQDAPUFY2013-FY2015CLA-BSISSICA-UTICentral line bundle complianceMRSA bacteremiaC. difficileInfluenza vaccination of HCW

“MDRO Bundle”

Increased Hand Hygiene Associated with Decreased MRSA Transmission

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Lancet 2000;356:1307-12

• Hand Hygiene• Contact precautions• Minimize shared equipment• Environmental cleaning• Healthcare-associated

infections preventive bundles– Catheter-associated BSI– Ventilator-associated

pneumonia– Catheter-associated UTI– SCIP measures

• Active surveillance cultures • Chlorhexidine baths• Antimicrobial stewardship• Patient and staff education

0 20 40 60 80 100

Room Door Handle

IV Pump Button

Bath Door Handle

Side Rails

BP Cuff

Overbed Table

Patient Gown

Bed Linen

Percent of Surfaces Positive for MRSA

Infect Control Hosp Epidemiol 1997;18:622-627

Role of Environmental Contamination

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Gowns Gloves

Contact with patient

Contact with environment

Contact Contamination

Per

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pos

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Who are you sleeping with?

Arch Intern Med 2006;166:1945-1951

40% increased risk of transmission associated with prior occupant’s MRSA or VRE carriage

Infect Control Hosp Epidemiol 2011;32:201-6

To Survey or Not to Survey?

• Interventions over 9 yr– Sterile CVC placement– Alcohol-based hand

hygiene– Hand hygiene campaign– ICU surveillance for

MRSA (16 months)• 29% of newly detected

MRSA carriers develop infection within 18 months

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ICU Non-ICU Hospital

No SurveillanceActive Surveillance

Surveillance Cultures Reduce MRSA Bacteremia

Reduced ICU transmission by 47%• 43 vs. 23 cases per 1000 at risk patientsClin Infect Dis 2003;36:281-5

Clin Infect Dis 2006;43:971-8

Inci

denc

e de

nsity

per

100

0 pt

-day

s75%

40%

67%

VA MRSA Initiative

N Engl J Med 2011;364:1419-30

• Decreased transmission

• Reduced HAIs• MRSA VAP• MRSA CLA-BSI• C. difficile in non-ICU• VRE in ICU and non-ICU

Active Surveillance and Contact Precautions in ICU

Control Intervention

MRSA or VRE colonization or infeciton (rate per 1000 pt-days)

35.6 40.4

Days in Contact Precautions (%) 38% 51%

Hand hygiene 59% 69%

Gloves 72% 82%

Gowns 59% 77%

N Engl J Med 2011;364:1407-18

• Cluster randomized study in 18 ICUs• Surveillance cultures for MRSA and VRE - Mean delay in results 5.2 days

Baseline CHG Baths P

MRSA acquisition* 5.04 3.44 0.046

VRE acquisition* 4.35 2.19 0.008

VRE bacteremia* 2.13 0.59 0.0006

Crit Care Med 2009;37:1858-1865*per 1000 pt-days

Daily Chlorhexidine Baths

Chlorhexidine baths in Trauma ICU

• Before and after introduction of daily CHG baths in TICU

• In pre-contact precaution era

• Reduction in CR-BSI from 8.4 to 2.1 per 1000 catheter-days (P=0.01)

• Reduction in MRSA VAP from 5.7 to 1.6 per 1000 vent-days (P=0.03)

Arch Surg 2010;145:240-246

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Nosoc MRSA Cases 87 84 88 72 71 62 72 63 46 40 27 41 30 36 39 37 29

Admits 4,4894,8044,8544,5104,5434,6844,8644,6184,8635,0775,1354,8234,7604,8615,2854,9464,668

MRSA Rate 19.4 17.5 18.1 16.0 15.6 13.2 14.8 13.6 9.5 7.9 5.3 8.5 6.3 7.4 7.4 7.5 6.2

QE Mar 2007

QE Jun

2007

QE Sep 2007

QE Dec 2007

QE Mar 2008

QE Jun

2008

QE Sep 2008

QE Dec 2008

QE Mar 2009

QE Jun

2009

QE Sep 2009

QE Dec 2009

QE Mar 2010

QE Jun

2010

QE Sep 2010

QE Dec 2010

QE Mar 2011

Confidential QI

HMC Nosocomial MRSA Rates

Quarterly

Source: Infection Control, for more information, please contact Dr. Tim Dellit, thdellit@u.washington.edu

Number of Cases2007: 331 Cases2008: 268 Cases2009: 154 Cases2010: 142 Cases

0.9 per 1000 pt-days

Which of the following bundle elements is NOT correct?

A. VAP and head of bed > 30 degreesB. VAP and sedation awakeningC. VAP and DVT prophylaxisD. Central line and maximum barriers including full body drape, sterile gown, sterile gloves, mask with eye protection, and haircoverE. Central line and povidone-iodine skin prepF. Central line and hand hygiene

Central Line-Associated BSI

• ICU CVC utilization 0.39 – 0.71 catheters/pt– 15 million catheter-days per year in US

• ICU rate 1.2 to 5.3 per 1000 catheter-days (NHSN mean)– 80,000 CR-BSI annually in US ICUs– Attributable mortality 0-35%

• Healthcare cost $296 million to $2.3 billion– Attributable cost $15,000-$56,000– Prolonged ICU and hospital LOS

Clin Infect Dis 2002;35:1281-307

National healthcare Safety Network (HNSN) Report, Data Summary for 2009

NHSN CLA-BSI Pathogens

1986-1989 1992-1999 2006-2007

Pathogen (%) (%) (%) Coag-negative staphylococci 27 37 34Staphylococcus aureus 16 13 10*Enterococcus 8 13 16Candida sp. 8 8 12Enterobacter 5 5 4Pseudomonas aeruginosa 4 4 3Klebsiella pneumoniae 4 3 5E. Coli 6 2 3

Clin Infect Dis 2002;35:1281-307

Infect Control Hosp Epidemiol 2008;29:996-1011

*MRSA 5.6%, MSSA 4.3%

Prevention of Catheter-Associated BSI

• IHI “Central Line Bundle”– Hand hygiene– Chlorhexidine skin prep– Maximal barriers

• Full drape• Mask, hair cover, sterile gown, sterile gloves

– Optimal catheter site selection– Daily review of line necessity

• Implementation AND documentation

Institute for Healthcare Improvement

Bundle in Action

Reduction in mean rate from 7.7 to 1.4 per 1000 catheter-days

N Engl J Med 2006;355:2725-32

Months After Implementation

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Baseline 0-3 4-6 7-9 10-12 13-15 16-18

Overall

Teaching Hospital

Non-teaching Hospital

< 200 beds

> 200 beds

UHC Benchmark of Key Performance Measures

Key Performance Measure Hospital Performance

Patient Level% of cases

median range

Central Venous Catheter Placed in the Subclavian Vein 44.2% 14.3 – 73.3%

Evidence of Maximal Barrier Precautions for Insertion 0.0% 0.0 – 8.2%

Hand Washing 0.0% 0.0 – 39.0%

Full Body Drape 3.0% 0.0 – 46.3%

Sterile Gloves and Gown 1.9% 0.0 – 39.0%

Cap and Mask 0.0% 0.0 – 13.6%

Chlorhexidine Skin Prep for Insertion 1.9% 0.0 – 98.1%

Daily Dressing Inspection 97.5% 25.1 – 100%

Daily Assessment of Medical Necessity to Continue CVC 16.4% 0.0 – 100%

Operational Yes % (n) Site #

Best Practice* CVC Insertion Policy 11.8% (2) 29, 89

Mandated Use of a CVC Insertion Checklist 11.8% (2) 84, 87

Infect Control Hosp Epidemiol 2008;29:440-2

National Reduction in CLA-BSI

JAMA 2009;301:727-36

MRSA Central Line-Associate BSI

JAMA 2009;301:727-36

50% reduction in MRSA CLA-BSI (0.43 vs 0.21 per 1000 catheter-days)

Hospital-Acquired UTI

Survey of Hospital Monitoring

• 40% of healthcare-associated infections• 80% due to indwelling urethral catheter

Potential Strategies

• Insertion/care• Catheter reminders/ automatic stop orders• Bladder US scanners• Condom catheters• Antimicrobial catheters

Aymptomatic bacteriuria vs.

Symptomatic UTI in patients without localizing GU symptoms

Clin Infect Dis 2008;46:243-500

102030405060708090

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Presence Duration UTI rates Feedback

No

mo

nito

ring

(%

)

CA-UTI PathogensNHSN 2006-2007

Candida sp, 21%

Pseudomonas , 10%

Enterococcus, 15%

Klebsiella sp, 9%

Enterobacter sp, 4%

E. coli, 21%

S, aureus, 2%

Acinetobacter , 1%Coag neg

Staphylococcus, 3%

Infect Control Hosp Epidemiol 2008;29:996-1011

Catheter-Associated UTI

• Duration of catheterization is primary risk

• Providers unaware of catheter status– Students 21%– Interns 22%– Residents 27%– Attendings 38%

• Daily assessment of need, especially when transferred from ICU to floor

Am J Med 2000;109:476-80

Ventilator-Associated Pneumonia• Rate 0.7 – 7.4 per 1000 ventilator days (NHSN 2009)

– 10-30% of intubated patients– Incidence increases with duration of MV

• Day 1-5: 3% risk per day• Day 6-10: 2% risk per day• > 10 days: 1% risk per day

• Attributable mortality rate 33-50%• Increased LOS 7-9 days• Cost of $40,000 per patient• Accounts for 50% of ICU antimicrobials• Clinical vs. microbiologic definitions

– Poor external quality measure

Am J Respir Crit Care Med 2005;171:388-416

BICU: Burn PICU: Pediatric med/surgCICU: Coronary NICU: NeurosurgeryCT ICU: Cardiothoracic SICU: SurgicalMICU: Medical TICU: Trauma

Rat

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NHSN Pooled Mean VAP by Unit2009 Report

Am J Infect Control 2009;37:783-805

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“Ventilator Bundle”

• Head of bed elevation > 30 degrees

• Daily “sedation awakening” and assessment of readiness to extubate

• Oral care (chlorhexidine)

• Peptic ulcer disease prophylaxis

• Deep vein thrombosis prophylaxis

*Institute for Healthcare Improvement

Late Onset VAP Pathogens

Pathogens July 03 – June 04 (N=138)

July 08 – June 09 (N=114)

July 09 – June 10 (N=83)

Acinetobacter 44 (32%) 4 (4%) ↓ 4 (5%) ↓

MRSA 32 (23%) 8 (7%) ↓ 2 (2%) ↓

MSSA 21 (15%) 30 (26%) 23 (28%)

Haemophilus 20 (14%) 24 (21%) 13 (16%)

Pseudomonas 13 (9%) 14 (12%) 15 (18%)

Enterobacter 4 (3%) 12 (11%) 4 (5%)

Klebsiella spp. 7 (5%) 7 (6%) 5 (6%)

Serratia spp. 5 (3%) 7 (6%) 1 (1%)

E. coli 6 (4%) 6 (5%) 1 (1%)

Which of the following has been demonstrated to reduce surgical site infections and is

currently part of SCIP recommendations?

A. Peri-operative prophylactic antibiotics should be given within 60 minutes after incision

B. Peri-operative prophylactic antibiotics should be given within 60 minutes before incision and discontinued within 24 hours

C. Peri-operative antibiotics should be continued until the drains are out

D. Nasal carriage of S. aureus should be eradicated prior to surgery

E. Pre-surgical bath with chlorhexidine

Surgical Care Improvement Project• Implemented by CDC and Centers for Medicare and Medicaid

Services in 2002• Nationally included procedures

– Cardiothoracic, vascular, colon, hip or knee arthroplasty, vaginal or abdominal hysterectomy

• Performance measures (Baseline of 34,133 medicare patients in 2001)– Antimicrobial prophylaxis within 1 hr of incision (55.7%)– Antimicrobial agent c/w current guidelines (92.6%)– Discontinuation within 24 hours after surgery (40.7%)

• Also, clipping rather than shaving, normothermia, glucose control, morning beta-blocker, DVT prophylaxis

• Role of MRSA screening?

Arch Surg 2005;140:174-82

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N Engl J Med 1992;326:281-6

Perioperative Prophylactic AntibioticsTiming of Administration

Infe

ctio

ns (

%)

Hours From Incision

14/369

5/699

5/1009

2/180

1/81

1/411/47

15/441

Society of Thoracic Surgeons• Rationale

– Unique patient risks• Cardiopulmonary bypass, systemic hypothermia

– Devastating sequelae of mediastinitis (7-20% mortality)– No randomized studies < 48 hrs in CT surgery

• Major Recommendations1. Postoperative prophylactic antibiotics are given for 48 hours or

less2. Duration not dependent on chest tube removal3. If risk for MRSA, then vancomycin AND cefazolin4. Routine mupirocin administration for all patients in the absence

of documented negative testing for staphylococcal colonization

Ann Thorac Surg 2006;81:397-404Ann Thorac Surg 2006;83:1569-76

Is Vancomycin Alone Adequate?

S. aureus, 40%

Anaerobes, 1%Fungi, 1%

Enterococcus, 3%

Other Gram-positives, 4%

Gram-negative Bacilli, 20%

Coagulase-negative Staphylococci, 21%

No Pathogen, 4%

Unknown, 7%

Acceptable for cardiac, vascular, or orthopedic surgery:

• Beta-lactam allergy

• Documented rationale

Pathogens causing deep SSI following CABG, Hip and Knee Arthroplasty

NNIS 1994-2003

Meta-analysis of Seven Randomized Studies: Glycopeptide vs. β-Lactam for Prevention of Surgical Site Infection after Cardiac Surgery

Clin Infect Dis 2004;38:1357-63

MSSA more frequent in vancomycin group 3.7% vs. 1.3%(J Thorac Cardiovasc Surg 2002;123:326-32)

Intranasal Mupirocin and Surgical Site Infections

• Nasal carriage of S. aureus and risk of surgical site infection– Orthopedic surgery with prosthetic implants in 272 patients, RR 8.9

(Infect Control Hosp Epidemiol 2000;21:319-323)– Cardiothoracic surgery in 1980 patients, OR 9.6 (J

Infect Dis 1995;171:216-9)• 10/10 pre- and post-surgical pairs identical by phage typing

• Randomized, double-blind, placebo-controlled trial of pre-surgical mupirocin in 3864 patients (N Eng J Med 2002;346:1871-7)

– No difference in nosocomial infections, nosocomial S. aureus infections, or S. aureus surgical site infections

– S. aureus carriers (N=891)• 4.5 fold increase in S. aureus SSI• Significant reduction in S. aureus nosocomial infections (4.0 vs. 7.7)• Trend towards decreased S. aureus SSI (3.7 vs. 5.9, 37%, P=0.15)• Same strain in nares and site of infection in 85%

Universal Screening of Surgical Patients?JAMA 2008;299:1149-57

• Prospective, cross-over study of 21,754 surgical patients– 87% on admission– MRSA colonization 5.1%

• Standard practices for all patients with MRSA– Contact precautions– Adjustment of pre-op prophylaxis– Intranasal mupirocin and chlorhexidine body wash

• No difference in MRSA SSI (0.99 vs. 1.14 per 100)– 34% of MRSA carriers did not receive appropriate pre-op

prophylaxis– None identified through outpatient screening developed MRSA

infection

2% Chlorhexidine and 70% alcohol (Chloraprep) vs. 10% Povidone Iodine for Surgical-Site Antisepsis

N Engl J Med 2010;362:18-26

NNT: 17 patients

• Randomized, multi-center

• 849 patients

• Clean-contaminated surgery

Pre-operative Chlorhexidine Baths

RR

Chlorhexidine vs. placebo 0.91 (0.80 to 1.04)

Chlorhexidine vs. bar soap 1.02 (0.57 to 1.84)

Chlorhexidine vs. no washing 0.36 (0.17 to 0.79)

Cochrane Review of six randomized trials with 10,007 patients

Cochrane Database Syst Rev. 2007 Apr 18;(2):CD004985. Review

It’s a small world…

26 y o medical student returns April 20, 2009 from an international elective in Mexico. On April 27 she presents to ED with 4 day h/o fever 39 C, cough, HA, myalgias, and diarrhea. That same day you hear reports of a novel Influenza A virus H1N1 associated with increased mortality in Mexico.

Which of the following is MOST correct regarding influenza?

A. No special precautions are necessary for patients with suspected influenza since it is not very transmissible.

B. Influenza is primarily transmitted by large droplets (> 5 microns), therefore healthcare workers should use Droplet Precautions with a surgical mask with eye protection for routine care to prevent contamination of mouth, nose, and conjunctiva.

C. Patients with 2009 H1N1 should be placed in airborne isolation with use of N-95 respirators while patients with H1N1 seasonal influenza should be placed in droplet precautions.

D. A negative rapid antigen test rules out influenza

E. Influenza vaccination of healthcare workers does not have an impact on patients.

Modes of Transmission

• Droplets– Thought to be primary mode of transmission– Coughing, sneezing, and talking– Heavy; settle within 6 feet of the source

• Airborne– Related to procedures → aerosolized particles

• Contact– Direct: skin-to-skin contact– Indirect: contact with virus in the environment

Respiratory Protection Debate• CDC (during 2009-2010 influenza season)

– Fit-tested N95 respirators for care of patients with 2009 H1N1– Prioritized usage if limited resources – Yet, Standard and Droplet Precautions for seasonal influenza?

• Infection Control and Infectious Diseases Societies*– No evidence that 2009 H1N1 transmitted differently than seasonal

influenza– Standard and Droplet Precautions for routine care

*Recommending organizations:• World Health Organization (WHO) • Infectious Disease Society of America• Healthcare Infection Control Practices • Society for Healthcare Epidemiology of America Advisory Committee (HICPAC) • Association of Professionals in Infection Control

Surgical Mask vs. N95 RespiratorRandomized Study

Characteristic Surgical Mask

N=212

N95 Respirator

N=210

P

Vaccinated 68 (30.2%) 62 (28.1%)

Lab-confirmed*

RT-PCR

H1N1 serology

Serology without symptoms

50 (23.6%)

6 (2.8%)

17 (8.0%)

29/44 (65.9%)

48 (22.9%)

4 (1.8%)

25 (11.9%)

31/44 (70.5%)

0.86

0.75

0.18

Physician visits 13 (6.1%) 13 (6.2%) 0.98

Influenza-like illness,

Fever and cough

9 (4.2%) 2 (1.0) 0.06

Work-related absenteeism 42 (19.8%) 39 (18.6) 0.75

JAMA 2009;302:1865-71*RT-PCR or serology

UW Medicine• Standard, Droplet, and Contact Precautions for routine

care– Place mask on coughing patients– Separate sick from non-sick patients– Surgical mask, eye protection, gown, and gloves

• N95 respirators for higher-risk aerosol-generating procedures– Intubation and extubation– Bronchoscopy– Open suctioning of airway– Cardiopulmonary resuscitation

Suspected or Confirmed Cases of Influenza

43 y o woman from Eritrea with 3 week h/o non-productive cough, fever, and night sweats

Now What?

AFB smear neg x 5 (3 sputum, 2 BAL)

Sputum AMTD neg

Which of the following is the BEST approach?

A. Remove from airborne isolation as a negative AMTD test rules out infectious TB

B. Begin 4 drug therapy and remove patient from airborne isolation due to multiple negative AFB smears

C. Begin 4 drug therapy and keep in airborne isolation

D. Obtain interferon-gamma releasing assay (IGRA) as a negative result would rule out TB

44 y o Vietnamese man with 6 month h/o pain and swelling of

left medial thigh associated with fevers and night sweats

Pulmonary Involvement in Extrapulmonary TB

• 72 patients with XPTB 36 lymph nodes 12 pleura 6 CNS 6 GI

• 57 had sputum collection

• Weight loss associated with positive sputum cx OR 4.3 (1.01-18.72)

Chest 2008;134:589-94

49% had abnormal CXR

Sputum AFB Smear

• Smear positive– 5,000-10,000 organisms per ml

of sputum must be present • Smear negative, culture-

positive TB– Responsible for roughly 17% of

TB transmission in San

Francisco and Vancouver

Am Rev Respir Dis 1966;95:998Lancet 1999;353;444, Thorax 2004;59:286

40-50% of pulmonary TB cases in King County are smear negative

Patient Safety and Infection Control

• UW Medicine Strategic Goals– Reduction in HAI– Expectation of hand hygiene with EVERY patient

EVERY the time

• WSHA elimination of HAI by 2012• Mandatory reporting of HAI

– CLA-BSI, VAP, selected surgical site infections

• MRSA legislation• Increased linkage of reimbursement to quality

– CMS preventable “medical errors”