Isolation Precautions Isolation Precautions

Allison McGeer, MSc, MD, FRCPC

Mount Sinai & Princess Margaret Hospitals, Toronto

Allison McGeer, MSc, MD, FRCPC

Mount Sinai & Princess Margaret Hospitals, Toronto

Routine Practices and Additional Precautions Infection Prevention and Control

Why worry about hospitals and Why worry about hospitals and infection?infection?

Pathogens are concentrated (people with them require admission)

Susceptible hosts are concentrated (ill people are susceptible, medical care makes them more so)

Contact is concentrated (many people in proximity; hands on care)

Industry safety, USIndustry safety, USIndustry safety, USIndustry safety, US

IndustryNumber of departures/

admissions

Number of deaths/

HAI deaths

Deaths per departure/

HAI deaths /admission

Airline 1,009,971,000 525 1/1,923,750

Hospital 34,890,678 88,000 1/396

Hospital-acquired Infections Hospital-acquired Infections Hospital-acquired Infections Hospital-acquired Infections

One in every 8 people who are admitted to a Canadian hospital develop an infection associated with their care

Once an hour, someone in Canada dies of a hospital-acquired infection

Once every 35 minutes, a new hospital patient in a Ontario becomes colonized with MRSA

One in every 8 people who are admitted to a Canadian hospital develop an infection associated with their care

Once an hour, someone in Canada dies of a hospital-acquired infection

Once every 35 minutes, a new hospital patient in a Ontario becomes colonized with MRSA

Infection controlInfection controlInfection controlInfection control Hospital design

– Prevention of legionellosis, aspergillosis, SSIs– Support for safe practice

Maintenance of practice to prevent infection– Surgery

prevention of SSI

– Procedures prevention of CRBSI, urinary tract infections, needlestick injuries

– Prevention of person to person transmission of pathogens Hand hygiene, additional precautions etc.

Hospital design– Prevention of legionellosis, aspergillosis, SSIs– Support for safe practice

Maintenance of practice to prevent infection– Surgery

prevention of SSI

– Procedures prevention of CRBSI, urinary tract infections, needlestick injuries

– Prevention of person to person transmission of pathogens Hand hygiene, additional precautions etc.

FundamentalsFundamentalsPrevention of transmissionPrevention of transmissionFundamentalsFundamentalsPrevention of transmissionPrevention of transmission

Hospital design Education Hand hygiene Routine practices and additional precautions Occupational Health

Hospital design Education Hand hygiene Routine practices and additional precautions Occupational Health

What does design have to do with What does design have to do with infection prevention?infection prevention?What does design have to do with What does design have to do with infection prevention?infection prevention?

Design to prevent infection

Design to facilitate practice to prevent infection (necessary

but not sufficient)

Design to prevent infection

Design to facilitate practice to prevent infection (necessary

but not sufficient)

No water pipes in ceiling

Mechanisms of transmissionMechanisms of transmissionMechanisms of transmissionMechanisms of transmission Airborne

Droplet

Contact (direct and indirect)

Airborne

Droplet

Contact (direct and indirect)

Protection from Airborne Infection Protection from Airborne Infection Protection from Airborne Infection Protection from Airborne Infection

Overall ventilation Adequate numbers of airborne isolation

rooms– Emergency department– Endoscopy suite– ICU– Medical/surgical wards

Overall ventilation Adequate numbers of airborne isolation

rooms– Emergency department– Endoscopy suite– ICU– Medical/surgical wards

Probability of infection as a function of Probability of infection as a function of ventilation, ICUventilation, ICUProbability of infection as a function of Probability of infection as a function of ventilation, ICUventilation, ICU

0102030405060708090

100

0 5 10 15 20 25 30 35 40

Total ventilation, x100 (L/sec)

Prob

abili

ty o

f inf

ectio

n (%

)

0102030405060708090

100

0 5 10 15 20 25 30 35 40

Total ventilation, x100 (L/sec)

Prob

abili

ty o

f inf

ectio

n (%

)

REALITY: Bronchoscopy, unsuspected TB 10/13 staff infected

WITH AIHA STANDARDS 2/13 infected

Nardell, Sem Resp Inf 2003:18:307

Risk factors for TB in Canadian hospital Risk factors for TB in Canadian hospital health care workershealth care workersRisk factors for TB in Canadian hospital Risk factors for TB in Canadian hospital health care workershealth care workers

Menzies Ann Int Med 2000:133:779

Risk factor Odds ratio

Air exchanges <2/hr 3.4 (2.1-5.8)

Number of patients with TB 2.2 (1.3-3.5)

Nurse, RT, physio, housekeeping 4.1, 6.3, 3.3, 4.2

Isolation room ventilation NS

Risk factors for TB in Canadian hospital Risk factors for TB in Canadian hospital laboratorieslaboratoriesRisk factors for TB in Canadian hospital Risk factors for TB in Canadian hospital laboratorieslaboratories

Menzies Am J Respir Crit Care Med 2002:67:599

Risk factor Odds ratio

Ratio of ventilation to that recommended (<0.5 compared to >=1)

1.3 (1.0-1.9)

Age of hospital wing (per 10 yrs) 1.5 (1.1-2.2)

% TB patients missed/delayed therapy

% TB patients admitted non-medical

% TB patients who died

2.0

2.0

2.5

Transmission of measlesTransmission of measlesTransmission of measlesTransmission of measles

Washington State, 1996– 42% measles cases health care associated

26% health care workers, 16% patients/visitors Relative risk of measles in HCW (US, 1980/1990s)

– 2.1 (1.8, 2.7)– 8.4 (6.6, 11)– 18.6 (7.4, 46)

Washington State, 1996– 42% measles cases health care associated

26% health care workers, 16% patients/visitors Relative risk of measles in HCW (US, 1980/1990s)

– 2.1 (1.8, 2.7)– 8.4 (6.6, 11)– 18.6 (7.4, 46)

Steingart ICHE 1999;20:115; Atkinson Am J Med 1991;91(3B):320S

Transmission of measles (2)Transmission of measles (2)Transmission of measles (2)Transmission of measles (2)

Location Odds ratio for acquiring measles associated with

ER visit for another reason

Lisbon, 1989 4.9 (1.8, 27)

Los Angeles, 1988/9 5.2 (1.7, 16)

Houston, 1988/9 8.4 (3.3, 21)

Farizo Pediatrics 1991;87:74; Miranda Int J Epidemiol 1994;23:843

Ventilation for protection Ventilation for protection Ventilation for protection Ventilation for protection

Meet AIHA guidelines– http://www.aia.org/publications/guidelinesabout.asp

Specific areas of concern– ER waiting room– Areas where bronchoscopy performed– Areas where unrecognized, infected patients are

most likely

Meet AIHA guidelines– http://www.aia.org/publications/guidelinesabout.asp

Specific areas of concern– ER waiting room– Areas where bronchoscopy performed– Areas where unrecognized, infected patients are

most likely

Airborne Isolation RoomsAirborne Isolation Rooms- Characteristics- CharacteristicsAirborne Isolation RoomsAirborne Isolation Rooms- Characteristics- Characteristics

Anteroom with sink Bathroom (off room) Negative pressure Requisite air changes (clean or filtered) AIR FLOW from staff to patient to exhaust

or filter

Be practical

Anteroom with sink Bathroom (off room) Negative pressure Requisite air changes (clean or filtered) AIR FLOW from staff to patient to exhaust

or filter

Be practical

Nardell, ICHE 1998;19:754

Private roomsPrivate rooms

Impact of change in room structure on Impact of change in room structure on nosocomial infectionnosocomial infectionImpact of change in room structure on Impact of change in room structure on nosocomial infectionnosocomial infection

Study Ward type

Comments Outcome

Smith (80) ICU Open to 40% singles

Decrease NI

Preston (81) ICU No change

Martiny (82) NICU (Inc staff also) Decrease NI

Mullen (97) ICU 7 single;8 open to 15 single

Decrease col MDR Acinetobacter

Kibbler (98) Med 5 bed to 4 beds/bay

Dec MRSA

transmission

Ben-Abraham (02) PICU Decrease NI

P

P

P

ATM

OutpatientEntrance

Drug Store EmergencyEntrance

Security EmergencyRegistration

Emergency

Nurse

Admitting

Vending

Machines

Waiting Room

Trauma

Room

Room 1

Room 2

Room 3

Room 4

Room 5

Room 6

Stock

Room

Room 7

Room 8

Room 9

Eye Room

Fracture

Room

Soiled

Linen

Shower

W CW C

Observation Room

Nursing Station

Ante

Room

Bed 1

Bed 2

Bed 3

Bed 4

Bed 5

Bed 6

Bed 1 Bed 2 Bed 3

Bed 4 Bed 5

Bed 8 Bed 7 Bed 6

Bed 1

Bed 2Bed3

SINKSSINKSSINKSSINKS ON THE WAY TO THE PATIENT Size: depth, diameter Wall-hung, with backsplash Porcelain or stainless steel Electric eye / foot pedal Temperature controls Tap centered over drain (reduces

splashing) No aerator Site for dirty paper towels Hand cream mounted

ON THE WAY TO THE PATIENT Size: depth, diameter Wall-hung, with backsplash Porcelain or stainless steel Electric eye / foot pedal Temperature controls Tap centered over drain (reduces

splashing) No aerator Site for dirty paper towels Hand cream mounted

CleaningCleaningCleaningCleaning Adequate space

– Dirty utility, housekeeping closet

– Storage dirty/clean equipment

Adequate time– Design to minimize

cleaning time

Adequate space– Dirty utility,

housekeeping closet– Storage dirty/clean

equipment

Adequate time– Design to minimize

cleaning time

FundamentalsFundamentalsPrevention of transmissionPrevention of transmissionFundamentalsFundamentalsPrevention of transmissionPrevention of transmission

Hospital design Education Hand hygiene Routine practices and additional precautions

Hospital design Education Hand hygiene Routine practices and additional precautions

HCW – source of infectionHCW – source of infectionHCW – source of infectionHCW – source of infection17%

83%

Unrecognized

Recognized

17%

83%

Unrecognized

Recognized

Risk factors for TB in Canadian hospital Risk factors for TB in Canadian hospital laboratorieslaboratoriesRisk factors for TB in Canadian hospital Risk factors for TB in Canadian hospital laboratorieslaboratories

Menzies Am J Respir Crit Care Med 2002:67:599

Risk factor Odds ratio

Ratio of ventilation to that recommended (<0.5 compared to >=1)

1.3 (1.0-1.9)

Age of hospital wing (per 10 yrs) 1.5 (1.1-2.2)

% TB patients missed/delayed therapy

% TB patients admitted non-medical

% TB patients who died

2.0

2.0

2.5

Degree of protection from SARS Degree of protection from SARS associated with knowledgeassociated with knowledgeDegree of protection from SARS Degree of protection from SARS associated with knowledgeassociated with knowledge

Infection control education

Lau (<2 hrs) 2 fold

(>=2 hrs) 60 fold

Shigayeva 4 fold

Number of Patients Colonized/Infected with MRSA, Number of Patients Colonized/Infected with MRSA, Ontario, 1992-2005Ontario, 1992-2005

0

2000

4000

6000

8000

10000

12000

No

. o

f cases o

f M

RS

A

.

QMP/LS Surveys, 1996-2005QMP/LS Surveys, 1996-2005

Incidence of MRSAIncidence of MRSAMount Sinai Hospital, 2002-2004Mount Sinai Hospital, 2002-2004Incidence of MRSAIncidence of MRSAMount Sinai Hospital, 2002-2004Mount Sinai Hospital, 2002-2004

0

2

4

6

8

10

12J M M J S N J M M J S N J M M J S N

2002 2003 2004

Rat

e pe

r 10

,000

pat

ient

day

s

Admitted with MRSA

0

2

4

6

8

10

12J M M J S N J M M J S N J M M J S N

2002 2003 2004

Rat

e pe

r 10

,000

pat

ient

day

s

Admitted with MRSA

Incidence of MRSAIncidence of MRSAMount Sinai Hospital, 2002-2004Mount Sinai Hospital, 2002-2004Incidence of MRSAIncidence of MRSAMount Sinai Hospital, 2002-2004Mount Sinai Hospital, 2002-2004

0

2

4

6

8

10

12J M M J S N J M M J S N J M M J S N

2002 2003 2004

Rat

e pe

r 10

,000

pat

ient

day

s Admitted with MRSAAcquired at MSH

0

2

4

6

8

10

12J M M J S N J M M J S N J M M J S N

2002 2003 2004

Rat

e pe

r 10

,000

pat

ient

day

s Admitted with MRSAAcquired at MSH

Nosocomial acquisition of MRSA per unprotected day Nosocomial acquisition of MRSA per unprotected day of exposure, MSH, of exposure, MSH, Nosocomial acquisition of MRSA per unprotected day Nosocomial acquisition of MRSA per unprotected day of exposure, MSH, of exposure, MSH,

0

0.2

0.4

0.6

0.8

1

1.2

0

0.2

0.4

0.6

0.8

1

1.2

0.32 cases / day

0.12 cases/ day, P=.002

University Hospitals, GenevaUniversity Hospitals, GenevaUniversity Hospitals, GenevaUniversity Hospitals, Geneva

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

1993 1994 1995 1996 1997 1998Year

new

MR

SA

per

100

ad

mis

sio

ns

0

2

4

6

8

10

12

14

16

18

20

No

soco

mia

l in

fect

ion

s p

er

100

adm

issi

on

s

MRSA

Nosocomial infections

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

1993 1994 1995 1996 1997 1998Year

new

MR

SA

per

100

ad

mis

sio

ns

0

2

4

6

8

10

12

14

16

18

20

No

soco

mia

l in

fect

ion

s p

er

100

adm

issi

on

s

MRSA

Nosocomial infections

Pittet, Lancet, 2000

Post-surgical acute care unit hand hygiene Post-surgical acute care unit hand hygiene programprogramPost-surgical acute care unit hand hygiene Post-surgical acute care unit hand hygiene programprogram

Pre-intervention

Post-intervention

Total infections per 100 patients 12.7 8.9

Total infections per 1000 pt-days 6.2 5.0

BSI per 1000 patient days 9.3 8.9

RTI per 1000 patient days 6.2 3.8

Swoboda, Crit Care Med, 2004

An organizational climate intervention associated An organizational climate intervention associated with increased handwashing and decreased with increased handwashing and decreased nosocomial infectionsnosocomial infections

An organizational climate intervention associated An organizational climate intervention associated with increased handwashing and decreased with increased handwashing and decreased nosocomial infectionsnosocomial infections

Commitment from administration– Education, messages from CEO, role modelling,

handwashing made core competency, incorporated into performance evaluation

Results– 40% increase in hand hygiene (vs. no change in control

hospital)– 33% reduction in MRSA, 85% decrease in VRE

Commitment from administration– Education, messages from CEO, role modelling,

handwashing made core competency, incorporated into performance evaluation

Results– 40% increase in hand hygiene (vs. no change in control

hospital)– 33% reduction in MRSA, 85% decrease in VRE

Larson Behav Med 2000;26:14

FundamentalsFundamentalsPrevention of transmissionPrevention of transmissionFundamentalsFundamentalsPrevention of transmissionPrevention of transmission

Hospital design Education Hand hygiene Routine practices and additional precautions

Hospital design Education Hand hygiene Routine practices and additional precautions

Routine practicesRoutine practices(US=Standard Precautions)(US=Standard Precautions)Routine practicesRoutine practices(US=Standard Precautions)(US=Standard Precautions)

Wear barriers to prevent:– Contact with blood/body fluids/non-intact skin– Exposure to droplets– (Gloves, eye protection, gowns)

Clean environmental surfaces/equipment

Wear barriers to prevent:– Contact with blood/body fluids/non-intact skin– Exposure to droplets– (Gloves, eye protection, gowns)

Clean environmental surfaces/equipment

When do you need additional precautions?When do you need additional precautions?When do you need additional precautions?When do you need additional precautions?

Diseases spread by the airborne route

Diseases spread by droplets

Diseases spread by contact with skin/the environment

Diseases spread by the airborne route

Diseases spread by droplets

Diseases spread by contact with skin/the environment

UNANSWERED QUESTION: IF HAND HYGIENE AND HOUSEKEEPING

ARE “ADEQUATE”, ARE ADDITIONALPRECAUTIONS NEEDED?

Additional precautionsAdditional precautionsAdditional precautionsAdditional precautions

MSH UHN

Airborne

Chickenpox

Airborne

Droplet/contact Droplet

Contact

MRSA

VRE/C diff

Contact

Full (droplet/contact/Air)

Pulmonary tuberculosis (TB)• Varicella/Chicken Pox • Disseminated Shingles/Zoster• Measles

Pulmonary tuberculosis (TB)• Varicella/Chicken Pox • Disseminated Shingles/Zoster• Measles

Infections spread by the airborne routeInfections spread by the airborne routeInfections spread by the airborne routeInfections spread by the airborne route

Pulmonary tuberculosis, MSH, 1998-2004Pulmonary tuberculosis, MSH, 1998-2004Pulmonary tuberculosis, MSH, 1998-2004Pulmonary tuberculosis, MSH, 1998-2004

0102030405060708090

Nu

mb

er

of

pa

tie

nts

1998 1999 2000 2001 2002 2003 2004

In-patients with pulmonary TB

Exposure days

Number patients in TB isolation

0102030405060708090

Nu

mb

er

of

pa

tie

nts

1998 1999 2000 2001 2002 2003 2004

In-patients with pulmonary TB

Exposure days

Number patients in TB isolation

Diseases spread by dropletsDiseases spread by dropletsDiseases spread by dropletsDiseases spread by droplets

Respiratory viruses Mycoplasma (primary atypical) pneumonia

N. meningitides Group A streptococci

Respiratory viruses Mycoplasma (primary atypical) pneumonia

N. meningitides Group A streptococci

Questions about droplet spreadQuestions about droplet spreadQuestions about droplet spreadQuestions about droplet spread

What is a droplet anyway?

What is contribution of droplet vs contact spread for these diseases?

How transmissible are they? How do patients acquire nosocomial respiratory viral diseases?

What is a droplet anyway?

What is contribution of droplet vs contact spread for these diseases?

How transmissible are they? How do patients acquire nosocomial respiratory viral diseases?

Expulsion of infectious material: Expulsion of infectious material: Particle SizeParticle SizeExpulsion of infectious material: Expulsion of infectious material: Particle SizeParticle Size

Diameter greater than 100 μm (Ballistic particles) – predominantly

affected by gravitational forces

Diameter greater than 100 μm (Ballistic particles) – predominantly

affected by gravitational forces

Kowalski and Bahnfleth, 1998; Tang JW et al. J Hosp Infect 2006

Nasopharyngeal-sized particles – 20-100 μm in diameter

Tracheobronchial-sized particles – 10 -20 μm in diameter

Alveolar-sized particles (pulmonary) – ≤10 μm in diameter

Nasopharyngeal-sized particles – 20-100 μm in diameter

Tracheobronchial-sized particles – 10 -20 μm in diameter

Alveolar-sized particles (pulmonary) – ≤10 μm in diameter Roy CJ NEJM 2004

Expulsion of infectious material: Expulsion of infectious material: Particle SizeParticle SizeExpulsion of infectious material: Expulsion of infectious material: Particle SizeParticle Size

Transmission of RSVTransmission of RSVVolunteers exposed to infected infantsVolunteers exposed to infected infantsTransmission of RSVTransmission of RSVVolunteers exposed to infected infantsVolunteers exposed to infected infants

Group No. (%) Infected

Sitters – sat next to crib, did not touch

0/14

Touchers – touched crib, bedclothes, toys, not child

4/10 (40%)

Cuddlers – direct contact with child 5/7 (71%)

Hall, CB J Pediatr 1981:99:100

RSVRSVRSVRSV Hall et al. (1986)

– Goggles prevent transmission of RSV to staff

Leclair et al (1987)– Compliance with gown and gloves reduces

transmission of RSV in hospital

Hall et al. (1986)– Goggles prevent transmission of RSV to staff

Leclair et al (1987)– Compliance with gown and gloves reduces

transmission of RSV in hospital

Degree of Protection from SARSDegree of Protection from SARSDegree of Protection from SARSDegree of Protection from SARS

Hand washing

Mask Glove

Shigayeva - 1.3 fold 1.5 fold

Loeb - 5 fold 2.5 fold

Lau 5 fold 3 fold 20 fold

Seto 5 fold 12 fold 2 fold

Teleman 15 fold 10 fold None

Median protection

Handwashing: 5 fold

Mask: 5 fold

Gloves: 2 fold

Median protection

Handwashing: 5 fold

Mask: 5 fold

Gloves: 2 fold

Face masks and hand hygiene to prevent Face masks and hand hygiene to prevent influenza transmission in householdsinfluenza transmission in householdsFace masks and hand hygiene to prevent Face masks and hand hygiene to prevent influenza transmission in householdsinfluenza transmission in households

Group Risk of lab-confirmed influenza (95% CI)

Control Reference

Hand hygiene 0.57 (.26, 1.22)

Hand hygiene + face mask 0.77 (.33, 1.55)

Cowling Ann Int Med; 2009;151 (Oct)http://www.annals.org/cgi/content/full/0000605-200910060-00142v1

Face masks and hand hygiene to prevent influenza Face masks and hand hygiene to prevent influenza transmission in households, intervention started <36 transmission in households, intervention started <36 hrs after symptom onsethrs after symptom onset

Face masks and hand hygiene to prevent influenza Face masks and hand hygiene to prevent influenza transmission in households, intervention started <36 transmission in households, intervention started <36 hrs after symptom onsethrs after symptom onset

Group Attack rate (95% CI)

Control 12 (7-18)

Hand hygiene 5 (1-11)

Hand hygiene + face mask 4 (1-7)

Cowling Ann Int Med; 2009;151 (Oct)http://www.annals.org/cgi/content/full/0000605-200910060-00142v1

P=.04

Don’t sit so close to meDon’t sit so close to meRisk of inf/col with Risk of inf/col with N. meningitidesN. meningitides during outbreak during outbreakDon’t sit so close to meDon’t sit so close to meRisk of inf/col with Risk of inf/col with N. meningitidesN. meningitides during outbreak during outbreak

Distance between chairs Percentage of carriers or cases

<102 cm 27% (20/73)*

>102 cm 7% (5/71)*

*P=0.0001 for the difference

New Engl J Med 1982;307:1255-7

Acquisition rates of GAS according to bed Acquisition rates of GAS according to bed distance from nearest carrierdistance from nearest carrierAcquisition rates of GAS according to bed Acquisition rates of GAS according to bed distance from nearest carrierdistance from nearest carrier

0

10

20

30

40

50

60

70

Acq

uisi

tion

of G

AS

per 1

000

man

-wee

ks

0-5 6-10 11-15 16-20 21-30 >30

Distance in Feet

0

10

20

30

40

50

60

70

Acq

uisi

tion

of G

AS

per 1

000

man

-wee

ks

0-5 6-10 11-15 16-20 21-30 >30

Distance in Feet

Detection of RSV RNA in samples from Detection of RSV RNA in samples from patient roomspatient roomsDetection of RSV RNA in samples from Detection of RSV RNA in samples from patient roomspatient rooms

AintablianICHE 1998:19:918

30% 19%14%

SARS in medical students exposed to a single SARS in medical students exposed to a single unrecognized patient, Hong Kongunrecognized patient, Hong KongSARS in medical students exposed to a single SARS in medical students exposed to a single unrecognized patient, Hong Kongunrecognized patient, Hong Kong

Wong, EID Feb2004 http://www.cdc.gov/ncidod/EID/vol10no2/03-0452.htm

SARS in medical students exposed to a single SARS in medical students exposed to a single unrecognized patient, Hong Kongunrecognized patient, Hong KongSARS in medical students exposed to a single SARS in medical students exposed to a single unrecognized patient, Hong Kongunrecognized patient, Hong Kong

Wong, EID Feb2004 http://www.cdc.gov/ncidod/EID/vol10no2/03-0452.htm

Space/patient larger than average North American observation area

Only 1/7 students infected while nebulizer was running

Attack rate: 3/3 students within 1m 4/8 1-12 m (same “cubicle”) 0/8 did not enter cubicle

(except 1 sr. med student, not in cubicle)

Increased risk associated with sitting closerBUT 90% of infected not within 3 feet

?exposure in lounge, while being seated, etc.

Olsen NEJM 2003:349:2416

Questions about droplet spreadQuestions about droplet spreadQuestions about droplet spreadQuestions about droplet spread

What is contribution of droplet vs contact spread for these diseases?

What is a droplet anyway?

How transmissible are they? How do patients acquire nosocomial respiratory viral diseases?

What is contribution of droplet vs contact spread for these diseases?

What is a droplet anyway?

How transmissible are they? How do patients acquire nosocomial respiratory viral diseases?

Impact of hand hygiene vs. Impact of hand hygiene vs. screening/precautions for MRSAscreening/precautions for MRSAImpact of hand hygiene vs. Impact of hand hygiene vs. screening/precautions for MRSAscreening/precautions for MRSA

0

0.2

0.4

0.6

0.8

1

1.2

1.4

New

MR

SA

per

100

0 pt

day

s No programHand hygieneScreening/precautionsBoth

0

0.2

0.4

0.6

0.8

1

1.2

1.4

New

MR

SA

per

100

0 pt

day

s No programHand hygieneScreening/precautionsBoth

Raboud et al, ICHE, 2005

Rates of MRSA TransmissionRates of MRSA Transmission

Source

Isolated Unisolated

Transmissions 5 10

Patient-days 558 71.5

Rates 0.009 0.140

RR=15.6, 95% CI=5.3-45.6, p<0.0001

J Jernigan et al., Am J Epi 1996;143:496.

Masks and MRSA - resultsMasks and MRSA - resultsMasks and MRSA - resultsMasks and MRSA - results

No Mask Mask P

Any pos screen 13/27 (48%) 7/27 (26%) .15

Total positive screens:

overall

nasal

throat/hands

42 (7%)

28 (4.7%)

14 (2.3%)

14 (2.5%)

1 (0.2%)

3 (0.6%)

<.001

<.001

.02

Transition: neg-pos 2.8% 1.1% <.05

Green K et al, ICAAC 2002 (Abtr K661).

Ostrowsky BE et al, NEJM 2001;344:1427-1433.

Salmenlinna S et al, Euro JCM & ID 2000;19:101-107.

Esveld MI et al, Ned Tijdschr Geneeskd 1999;143:205-8.

Armstrong-Evans M et al, ICHE 1999;20:312-317.

Jochimsen E et al, ICHE 1999;20:106-109.

Verhoef J et al. Eur J Clin Micro Infect Dis 1999;18:461-466.

Kotilainen P et al. Emerg Infect Dis. 2003;9:169-75.

Silverblatt FJ et al, J Am Geriatr Soc 2000;48:1211-1215.

Studies Reporting Control of MRSA & VRE in Nonacademic Settings Using Active

Surveillance Cultures & Contact Precautions

Studies Showing Cost Benefit of ASC & CP forControlling MRSA & VRE

Jernigan JA et al, ICHE 1995;16:686.

Papia G et al, ICHE 1999;20:473-477.

Chaix et al, JAMA 1999;282:1745.

Montecalvo MA et al, ICHE 2001;22:437-42.

Bronstein M et al, SHEA 2002 (Abst 47, pg 51).

Karchmer TB et al, J Hosp Infect 2002;51:126.

Muto CA et al, ICHE 2002;23:429-435.

Calfee DP et al, ICHE 2002;23:407-410.

Lucet J et al, Arch Int Med 2003;163:181-88.

Evidence for environmental transmissionEvidence for environmental transmissionEvidence for environmental transmissionEvidence for environmental transmission

Organism can be isolated from the environment Organism can be cultured from gloves/hands that

have touched the environment Organism can be transferred from gloves/hands to a

clean site (patient or environment Exposure to contamination is associated with

acquisition of colonization/infection Reduction in contamination is associated with

reduced acquisition of colonization/infection

Organism can be isolated from the environment Organism can be cultured from gloves/hands that

have touched the environment Organism can be transferred from gloves/hands to a

clean site (patient or environment Exposure to contamination is associated with

acquisition of colonization/infection Reduction in contamination is associated with

reduced acquisition of colonization/infection

Evidence for environmental transmissionEvidence for environmental transmissionEvidence for environmental transmissionEvidence for environmental transmission GAS - ?implicated in 2/61 reported outbreaks

– bidet, plastic sheet RSV - Hall et al. transmission to volunteers MRSA

– before/after study of intervention: increase cleaning with focus on shared equipment/ dust removal (J Hosp Infect. 2001;49:109)

– Increased risk of MRSA acquisition by patients being admitted to room previously occupied by MRSA patient (3.9% vs. 2.9%, P=.04) (Huang AIM 2006;166:1945)

VRE – unpublished outbreak data C. difficile - evidence from outbreaks of “room” effect

GAS - ?implicated in 2/61 reported outbreaks– bidet, plastic sheet

RSV - Hall et al. transmission to volunteers MRSA

– before/after study of intervention: increase cleaning with focus on shared equipment/ dust removal (J Hosp Infect. 2001;49:109)

– Increased risk of MRSA acquisition by patients being admitted to room previously occupied by MRSA patient (3.9% vs. 2.9%, P=.04) (Huang AIM 2006;166:1945)

VRE – unpublished outbreak data C. difficile - evidence from outbreaks of “room” effect

Environmental non-transmissionEnvironmental non-transmissionEnvironmental non-transmissionEnvironmental non-transmission

0

10

20

30

40

50

60

70

Acqu

isiti

ons

of G

AS p

er 1

000

man

-day

s

Blankets with streptococci Blankets without streptococci0

10

20

30

40

50

60

70

Acqu

isiti

ons

of G

AS p

er 1

000

man

-day

s

Blankets with streptococci Blankets without streptococci

GuidelinesGuidelinesGuidelinesGuidelines

Canadian infection control guidelines– http://www.phac-aspc.gc.ca/dpg_e.html#infection

US HICPAC guidelines– http://www.cdc.gov/ncidod/hip/Guide/guide.htm

AIA design guidelines http://www.aia.org/publications/guidelinesabout.asp

Canadian infection control guidelines– http://www.phac-aspc.gc.ca/dpg_e.html#infection

US HICPAC guidelines– http://www.cdc.gov/ncidod/hip/Guide/guide.htm

AIA design guidelines http://www.aia.org/publications/guidelinesabout.asp