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5/30/2017
1
Prevention of Nosocomial Infections
Manuel D. Rodriguez DO, MS, MPH, FACP
June 2017
Disclosures
Member of the Speaker’s Bureau for AllerganDalvance and Teflaro
I intend to discuss off-label uses of drugs during this talk
Objectives
Define nosocomial infection
Review the four most common causes of nosocomial infectionsDiagnosis
Treatment
Prevention
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Objectives
Discuss other potential preventive strategies for nosocomial infectionsHand Hygiene
Isolation
Vaccines
Nosocomial Infections
The term "nosocomial" comes from two Greek words: "nosus" meaning "disease" + "komeion" meaning "to take care of."
“Nosocomial" should apply to any disease contracted by a patient while under medical care. Not those that are just “Hospital Acquired”
A nosocomial infection is specifically one that was not present or incubating prior to the patient's admission to the hospital.
Nosocomial Infections
Infections acquired in the hospital that are caused by viral, bacterial, or fungal pathogens
The most common causes include:
Blood stream infections (BSI)
Pneumonia (e.g. ventilator associated pneumonia [VAP])
Urinary tract infections (UTIs)
Clostridium difficile infection (CDI)
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Risk factors for developing a nosocomial infection
Duration of hospital stay
Indwelling catheters
Mechanical ventilation
Use of total parenteral nutrition (TPN)
Risk factors for developing a nosocomial infection
Antibiotic usage
Use of histamine (H2) receptor blockers (owing to relative bacterial overgrowth)
Age—more common in neonates, infants, and the elderly
Immune deficiency
Catheter-Related Bloodstream Infections
(CRBSI)
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CRBSI
In ICUs 15 million central vascular catheter (CVC) line days in the ICU per year are reported
CRBSI increase length of stay and cost
There are 80,000 CRBSIs in ICUs each year
Hospital wide a total of 250,000 cases of BSIs have been estimated to occur annually
CRBSI
Based on moderate evidence the use a midline catheter or peripherally inserted central catheter (PICC), instead of a short peripheral catheter, when the duration of IV therapy will likely exceed 6 days
Gauze or opaque dressings should not be used to cover the catheter insertion site
Remove the catheter if the patient develops signs of phlebitis (warmth, tenderness, erythema or palpable venous cord), infection, or a malfunctioning catheter
CRBSI
Obtain paired blood cultures from the CVC and peripheral stick when CRBSI is suspected prior to starting antibiotics
Cather tip culture previously recommended in the IDSA guidelines from 2009 is no longer recommended
CVC entry site exudate culture should be obtained if present
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CRBSI treatment
Duration of antimicrobial therapy for CRBSI depends on the clinical circumstances.
In uncomplicated CRBSI with negative blood cultures following catheter removal or guidewire exchange and institution of appropriate antibiotic therapy, the duration of therapy is usually 10 to 14 days; day 1 is the first day of which negative blood cultures
CRBSI Treatment
Four- Six weeks of therapy is recommended in patients with recent prosthetic valve placement or those with prosthetic valves, even if investigation fails to show evidence of endocarditis.
In the setting of persistent bacteremia >72 hours following catheter removal the recommended duration is at least four to six weeks.
CRBSI Treatment
Patients with complications related to bacteremia:Suppurative thrombophlebitisEndocarditisOsteomyelitisMetastatic infection
In general, the patient should receive antibiotic therapy for at least 7 to 10 days following device removal prior to the placement of a new CVC
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CRBSI Treatment
* Penicillin, if the strain is susceptible.¶ Pediatric experience is limited.Δ Additional alternative agents include linezolid, tedizolid, ceftaroline, telavancin, dalbavancin, and oritavancin.◊ Pending susceptibility results for the isolate.1.References: Fernandez-Hidalgo N, Almirante B, Gavalda J, et al. Ampicillin plus ceftriaxone is as effective as ampicillin plus gentamicin for treating Enterococcus faecalis infective endocarditis. Clin Infect Dis 2013; 56:1261.
CRBSI Treatment
TMP-SMX: trimethoprim-sulfamethoxazole; ESBL: extended-spectrum beta-lactamase.* Penicillin, if the strain is susceptible.¶ Pediatric experience is limited.Δ Additional alternative agents include linezolid, tedizolid, ceftaroline, telavancin, dalbavancin, and oritavancin.◊ Pending susceptibility results for the isolate.1.References: Fernandez-Hidalgo N, Almirante B, Gavalda J, et al. Ampicillin plus ceftriaxone is as effective as ampicillin plus gentamicin for treating Enterococcus faecalis infective endocarditis. Clin Infect Dis 2013; 56:1261.2.Farrell DJ, Flamm RK, Sader HS, et al. Antimicrobial activity of ceftolozane-tazobactam tested against Enteriobacteriaceae and Pseudomonas aeruginosa with various resistance patterns isolated in U.S. hospitals (2011-2012). Antimicrob Agents Chemother 2013; 57:6305.3.Zhanel GG, Lawson CD, Adam H, et al. Ceftazidime-avibactam: a novel cephalosporin/B-lactamase inhibitor combination. Drugs 2013; 2:159.
CRBSI Treatment
TMP-SMX: trimethoprim-sulfamethoxazole; ESBL: extended-spectrum beta-lactamase.* Penicillin, if the strain is susceptible.¶ Pediatric experience is limited.Δ Additional alternative agents include linezolid, tedizolid, ceftaroline, telavancin, dalbavancin, and oritavancin.◊ Pending susceptibility results for the isolate.1.References: Fernandez-Hidalgo N, Almirante B, Gavalda J, et al. Ampicillin plus ceftriaxone is as effective as ampicillin plus gentamicin for treating Enterococcus faecalis infective endocarditis. ClinInfect Dis 2013; 56:1261.2.Farrell DJ, Flamm RK, Sader HS, et al. Antimicrobial activity of ceftolozane-tazobactam tested against Enteriobacteriaceae and Pseudomonas aeruginosa with various resistance patterns isolated in U.S. hospitals (2011-2012). Antimicrob Agents Chemother 2013; 57:6305.3.Zhanel GG, Lawson CD, Adam H, et al. Ceftazidime-avibactam: a novel cephalosporin/B-lactamase inhibitor combination. Drugs 2013; 2:159.
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CRBSI General Guide
No need to replace a peripheral catheter any more than every 72-96 hours to reduce risk of infection and phlebitis in adults
Do not use fever alone as an indication to remove a CVC unless there is clinical suspicion
Guidewire exchange of a CVC can be performed if there is no sign of infection
CRBSI Prevention
Avoid the use of a femoral site for CVC
Subclavian site remains preferred over a jugular >>>> femoral In renal patients the subclavian site may need
to be avoided due to risk of stenosis
CRBSI Prevention
Ultrasound guidance should be used in placement of CVCs
Place a CVC with the minimum amount of ports needed
Remove the CVC as soon as possible
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Hospital Acquired and Ventilator Associated
Pneumonia (HAP/VAP)
HAP/VAP
Pneumonia that develops after more than 48 hours of hospitalization or mechanical ventilation.
Incidence of VAP ranges 10 to 25%
Estimated all-cause mortality of VAP is 25 to 50 %
HAP/VAP
Moving away from the term Healthcare Associated Pneumonia (HCAP); diagnosis made < 48 hours after admission with any of the following risk factors:1. Hospitalized in an acute care hospital for
> 48 hours 2. Resided in a nursing home or long-term care
facility;3. Received recent IV antibiotic therapy,
chemotherapy, or wound care within the 30 days preceding the current diagnosis;
4. Attended a hospital or hemodialysis clinic
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Date of download: 5/8/2017Copyright © 2000 American Medical Association. All
rights reserved.
From: Ventilator-Associated Pneumonia
Arch Intern Med. 2000;160(13):1926-1936. doi:10.1001/archinte.160.13.1926
Potential sources of bacteria causing ventilator-associated pneumonia. Bacteria residing in the oropharynx and gastrointestinal tract can contaminate the subglottic secretion pool, as demonstrated. Subglottic secretions above the endotracheal tube cuff are aspirated into the trachea and disseminated into the distal airways and lung parenchyma by the force of the ventilator (inset).
Figure Legend:
HAP/VAP
Subglottic suctioning endotracheal tubes was shown in a meta-analysis to have lower rated of VAP in patients who were intubated for more than 24 hours
Head of bed elevation has not been shown to definitively reduce the rates of VAP. Clinical guidelines recommend that the head of
the bed be elevated at least 30 degrees and patients not be left supine to prevent aspiration
HAP/VAP
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HAP/VAP
HAP/VAP
Ceftolozane/Tazobactam is in a phase 3 study to evaluate its efficacy in VAP. Currently it is being used off label for pneumonia at a higher dose of 3g IV Q8 hours instead of 1.5g IV Q8 hours
Ceftazidime/Avibactam just completed a study on HAP in February 2017. Results were presented at the 27th annual meeting of the European Congress of Clinical Microbiology and Infectious Disease
HAP/VAP Prevention
Use non-invasive positive pressure ventilation (NPPV) to prevent endotracheal intubation
Once intubated, encourage daily weaning trials and sedation holidays
Re-intubation is associated with a higher rate of VAP due to the increase risks of aspiration
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HAP/VAP Prevention
Antimicrobial-coated endotracheal tubes were shown in the North American Silver-Coated Endotracheal Tube (NASCENT) study to be associated with lower rates of VAP occurrence and microbiologically confirmed VAP when compared to conventional tubes
Theses tubes were not associated with decrease mortality, duration on vent, or length of stay in the ICU and were more costly ($90 vs $2)
HAP/VAP Prevention
Selective digestive tract decolonization (SDD) –Not recommended due to increase risk of the development of bacterial resistance
Oral decontamination using chlorohexidine has been shown in systemic reviews and meta-analysis to reduce the rate of VAPStrength of chlorohexidine affects outcomeEffect is most pronounced in cardiac surgery
patients
HAP/VAP Prevention
One of the largest hurdles if to have health care providers follow published guideline recommendations.Use of “bundles” in the ICU have not been well
studied, but generally recommendedEven when implemented studies have shown
that ICU physicians and nurses do not follow published recommendations for prevention of VAP; 37% and 22.3% respectively
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Catheter Associated Urinary Tract Infection (CA-UTI)
CA-UTI
The most common cause of health care-associated infection world wide
Rates of unnecessary urethral catheterization has been reported between 21% and 50% in studies
CA-UTI
Definition:The presence of symptoms or signs compatible
with UTI with no other identified source of infection in a patient who has an indwelling catheter in place
≥103 colony forming units (cfu)/mL of ≥1 bacterial species in a single catheter urine specimen or in a midstream voided urine specimen from a patient whose catheter has been removed within the previous 48 hrs
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CA-UTI
This differs from catheter associated asymptomatic bacteriuria (CA-ASB)
CA-ASB should not be screened for except in specific circumstances:Pregnancy
Research
CA-UTI
Signs and symptoms compatible with CA-UTI include new onset or worsening
Fever Flank pain
Rigors Costovertebral angle tenderness
Altered mental statusAcute hematuria
Malaise Pelvic discomfort
Lethargy with no other identified cause
CA-UTI
In those whose catheters have been removed, dysuria, urgent or frequent urination, or suprapubic pain or tenderness
In patients with spinal cord injury, increased spasticity, autonomic dysreflexia, or sense of unease are also compatible with possible CA-UTI
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CA-UTI
The presence of pyuria in an asymptomatic patient is not an indication for antimicrobial treatment regardless of the amount
Absence of pyuria in a patient with symptoms of CA-UTI should prompt for investigation of other causes
Odor or cloudiness of the urine alone should not be used to differentiate CA-ASB from CA-UTI or as an indication for urine culture or antimicrobial therapy
CA-UTI Diagnosis
A urine culture should be obtained prior to the start of antimicrobials in an individual suspected of having a CA-UTI
The specimen should be collected after a new catheter is in place
If the catheter is no longer needed a culture of a voided midstream urine specimen should be obtained
CA-UTI Treatment
Target empiric antimicrobial treatment based on local antibiograms
Duration of treatment is generally 7 days10-14 days of treatment can be considered in
patients who are slow to respond to initially
In women ≤ 65 y/o whose catheter has been removed and has no signs of pyelonephritis a 3 day course of antibiotics could be considered
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CA-UTI Funguria
Common finding in uncontrolled hospitalized diabetics, patients in the ICU, patients on prolonged courses of antibiotics who are asymptomatic should not be treated It is not a marker for systemic disease in
asymptomatic patients It is a marker for colonization
CA-UTI Funguria
Asymptomatic Funguria does not require treatmentExceptions:
NeutropeniaVery low birthweight infants (<1500 g)Urinary tract manipulation
Renal transplant is no longer considered an absolute indication to treat asymptomatic Candiduria
CA-UTI Funguria Treatment
Remove the catheter
For fluconazole sensitive Candida:200-400mg daily for 14 days
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CA-UTI Funguria Treatment
If fluconazole resistant:C. glabrata: amphotericin B deoxycholate 0.3
to 0.6 mg/kg IV daily with or without flucytosine 25 mg/kg orally four times daily for 1 to 7 days or flucytosine alone for two weeks
C. krusei: amphotericin B deoxycholate 0.3 to 0.6 mg/kg IV for 1 to 7 days
Amphotericin B deoxycholate bladder irrigation 50 mg/L sterile water daily for 5 days can be used for patients
CA-UTI Prevention
Possible reasons to use a cathetera) Urinary retentionb) Obstruction to the urinary tractc) Close monitoring of the urine output of
critically ill patientsd) Urinary incontinence that poses a risk to the
patient because of Stage 3 or greater ulcer to the sacral area
e) Comfort care for terminally ill patients
CA-UTI Prevention
There is insufficient evidence to recommend the use of antimicrobial coated catheters
Guidelines do not recommend the use of prophylactic antibiotics in patients with urinary catheters
Systemic
Bladder irrigation
Topical
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CA-UTI Prevention
Consider alternatives to the indwelling catheter such as intermittent catheterization
If a catheter is in place document why Assess the need for the inserted catheter
dailyRemove it as soon as possible
Case Presentation Holroyd KB, Rittenberg A, Pahwa A. Misanalysis of Urinalysis. A Teachable
Moment. JAMA Intern Med. 2016;176(4):432-433. doi:10.1001/jamainternmed.2016.0067
Case Presentation
64-year-old woman with history of a Bertolottisyndrome presented to an ER due to symptoms related to medication withdrawal.
She was concerned that her medication was habit forming and within 24 hours after stopping her tramadol and tizanidine developed a cough, myalgias, nausea, weakness and rhinorrhea; similar symptoms to when she had done this in the past.
ROS negative for GI symptoms such as abdominal pain or diarrhea.
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Case Presentation
Afebrile, blood pressure 150/70 mmHg, heart rate 115 bpm
ER performed a urinalysis although the patient had no evidence of urinary symptoms.
UA showed 4 epithelial cells per high-powered field (hpf), 10 WBC per hpf as well as large leukocyte esterase, negative nitrites and only rare bacteria.
Case Presentation
Prior to discharge the patient was prescribed a seven-day course of cefpodoxime 100 mg twice a day.
No urine culture was ordered
Case Presentation
4-5 days after ER discharge the patient developed watery diarrhea
The frequency increased to 10 per day with associated lower abdominal pain
She developed fever as high as 39.2°C and presented to the emergency department
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Case Presentation
Vitals at that presentation showed fever, BP 105/71 mmHg, HR 128 bpm, RR 20 bpm
Repeat urinalysis showed pyuria once again.
CBC showed elevated white count of 19.3 K/mm3
Case Presentation
The patient was admitted for sepsis and because of recent antibiotic use was started on oral vancomycin empirically
Stool PCR was positive for C. difficile toxin
Over the next 4 days the patient’s diarrhea decreased in frequency and her fever as well as elevated WBCs resolved
Case Presentation
She was eventually discharged to complete her course of oral vancomycin
In a recent study of a University Hospital and was found that 62% of patients admitted to the General medicine service had a urinalysis despite 85% of these patients not having any symptoms related to a urinary tract infection
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Clostridium difficile infection (CDI)
CDI
Clostridium difficile is a causative agent of antibiotic associated colitis
It is caused by a disruption in the normal fecal flora in a patient who have been previously exposed/colonized with C. diff
The route of transmission of C. diff is fecal-oral
Risk factors for acquiring C. diff include exposure to health care settings such as hospitals, nursing homes, other long-term care facilities, and dialysis centers
CDI
Risk factors
Antibiotic exposure: Highest Risk: fluoroquinolones > clindamycin
> broad spectrum cephalosporins > penicillins
Moderate risk: macrolides > trimethoprim-sulfamethoxazole
Rare: aminoglycosides > tetracyclines > metronidazole > vancomycin
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CDI
Risk factors
Age ≥ 65
Gastric acid suppression with either a proton pump inhibitor of H-2 blocker
CDI- Treatment
Stop inciting antibiotic(s)
Begin treatment if clinical suspicion high
Assess severity of disease
CDI- Treatment
Scoring system devised to identify patients with severe infection One point:
Age >60 yearsTemperature >38.3ºC, Serum albumin <2.5 g/dL (25 g/L)WBC >15,000 cells/microL
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CDI- Treatment
Scoring system devised to identify patients with severe infection
Two points:
Endoscopic evidence of pseudomembranous colitis OR
Treatment in the intensive care unit
CDI- Treatment
Mild to Moderate disease initial episode:
Metronidazole 500mg PO TID or 250mg PO QID for 10-14 daysAvoid use of oral vancomycin when possible
to avoid increased risk of developing vancomycin resistant enterococcus
CDI- Treatment
Mild to Moderate disease initial episode:
Vancomycin 125mg PO Q6 hours for 10-14 daysReserve for pregnant woman or those
allergic/intolerant to metronidazole
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CDI- Treatment
Second episode:Repeat same treatmentMost studies do not recommend further
treatment with metronidazole after a second course of due to it dose dependent risk of peripheral neuropathy
Consider fidaxomicin 200mg PO BID for 10 days
CDI- Treatment
Recurrent disease:Prolonged vancomycin taper:
125mg PO QID for 7-14 days125mg PO BID for 7 days125mg PO Daily for 7 days125mg PO Every Other Day for 7 days125mg PO Every Third Day for 14 days
CDI- Treatment
Recurrent disease:Vancomycin 125mg PO Q6 hours x 14 days
followed by rifaximin 400 mg three times for 20 days
Consider fecal transplant
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CDI- Treatment
Severe disease:Vancomycin 125mg PO Q6 hours
Higher doses of vancomycin (250mg, 500mg) Has not been shown to be of benefit given dose absorption kinetics or oral vancomycin in the colon
CDI- Treatment
Add IV antibiotics:Patients unable to tolerate PO or have signs
of ileus
Metronidazole 500mg IV Q8 hours
Tigecycline was used in a small case series of 4 refractory patients with some success
CDI- Treatment
Vancomycin enemaPatients with ileus and/or cannot tolerate
oral vancomycin
500 mg every 6 hours (in 100 mL 0.9% sodium chloride)
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CDI- Treatment
Surgery In patient with severe CDI surgical intervention
is advisable in the setting of peritoneal signs, severe ileus, or toxic megacolon.
Subtotal colectomy
Diverting loop ileostomy and colonic lavage
C. diff Treatment
Monoclonal antibodiesBezlotoxumab FDA approved in 2016 for
use in secondary prevention Patients at high risk for recurrent CDIAge ≥ 65
Bezlotoxumab binds to toxin BNot to be used in severe disease
C. diff Treatment
IV immunoglobulins (IVIG)Small case reports and limited data on
efficacy
Not currently recommended
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CDI - Prevention
Use antibiotics sparingly
Avoid gastric acid suppression
Follow contact isolation practices to prevent spread in hospitalized patients*
C. Diff Treatment
Hand wash with soap and waterAlcohol based scrubs used in the US cannot kill
C. diff spores
Patient’s at high risk of recurrent CDI Consider prophylactic vancomycin 125mg PO
BID vs QID
Hand Hygiene – how compliant are we?
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Hand Hygiene – The Lesson of Semmelweis
Ignaz Semmelweis was a physician in 1847 Vienna, Austria
He noticed that fever was more common on a maternity ward where medical students worked than it was on the ward where midwives provided care.
He believed that the students were contaminating their hands while dissecting cadavers and began telling them to was their hands in chlorinated lime after dissection and before examining patients.
Hand Hygiene – The Lesson of Semmelweis
The rate of infection fell sharply, as did the mortality rate.
12 women developed postpartum fever on a ward where the students had no contact with cadavers which prompted Semmelweis to infer that infection was also transmitted by living organisms
He began to ask that hand washing be performed between all patient examinations.
Hand Hygiene – The Lesson of Semmelweis
Few physicians believed Semmelweis’ theory and refused to publish his findings.
In 1851, and again in 1855, he was appointed to hospitals with high infection and mortality rates-and his hand antisepsis methods resulted in significant decreases in infection and mortality.
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Hand Hygiene
Globally health care workers are compliant with hand hygiene ~50%
There are lower rates of compliance with physicians when compared to nursing and allied health staff
In addition, there is variability in the type of institution and level of training as well as specialty
Hand hygiene – excuses?
I’m too busy
My skin gets too irritated
I wore gloves
I didn’t think of it
Patient care comes first
Hand Hygiene
Before and after any direct contact with patients
Immediately after removal of gloves
Before handling an invasive device not requiring a surgical procedure, including central intravascular catheters, urinary catheters or peripheral vascular catheters
After touching blood, body fluids, secretions, excretions, non-intact skin or contaminated items, even if gloves are worn
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Hand Hygiene
When moving from a contaminated to a clean body site on the same patient
After contact with inanimate objects in the immediate vicinity of the patient
After using the lavatory
Isolation
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Standard Precautions
Applies to all patientsHand hygiene
Use of Personal Protective Equipment (PPE)
Respiratory hygiene
Contact precautions
Infectious diarrhea
Multidrug resistant organisms (MDRO)
Viral conjunctivitis
Lice, scabies
Contact precautions
Adenovirus (contact + droplet)
Respiratory Syncytial Virus (RSV)
Severe Acute Respiratory Syndrome (SARS)
Zoster
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Droplet precautions
Use of Surgical maskAdenovirus (droplet + contact)
Influenza
Mumps
Rubella
Meningococcal
Airborne Precautions
Use of N95 mask
Measles
Tuberculosis (primary or laryngeal)
Varicella (airborne + contact)
Airborne Precautions
Use of N95 maskZoster (disseminated or immunocompromised
patient); (airborne + contact)
Middle Eastern Respiratory Syndrome Coronavirus (MERS-CoV)
SARS
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Vaccinations
Vaccines
Primary prevention is best
No vaccine is 100% effective
Herd immunity helps to increase overall vaccine effectiveness
Flu Vaccines
This year the following flu vaccines were recommended:Standard trivalent inactivated vaccine
High dose, including Quadrivalent
Recombinant Cell culture
Adjuvant
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Flu VaccineEarly-season 2016–17 flu vaccination coverage among
HCP was 68.5%, similar to early-season coverage during the 2015–16 season (66.7%).During the previous two seasons, flu vaccination coverage
increased by 12–13 percentage points from early season to the end of the season.
https://www.cdc.gov/flu/fluvaxview/hcp-ips-nov2016.htm
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Flu Vaccine
By occupation:
Highest among physicians (83.0%),
Nurse practitioners/physician assistants (82.8%),
Pharmacists (81.4%),
Nurses (80.7%),
Other clinical professionals (72.3%).
https://www.cdc.gov/flu/fluvaxview/hcp-ips-nov2016.htm
Flu Vaccine
Lowest:Administrative and nonclinical support staff
(65.3%) Assistants and aides (56.8%).
By work setting:Early season flu vaccination highest among HCP
working in hospitals (80.8%). Lowest among HCP working in long-term care (LTC)
settings (55.1%).
Flu Vaccine
The most common reason reported for not getting vaccinated:Fear of experiencing side effects or
Getting sick from the vaccine
The second most common reason was that they don’t think that flu vaccines work.
https://www.cdc.gov/flu/fluvaxview/hcp-ips-nov2016.htm
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Pneumococcal Vaccine
Effective in preventing invasive pneumococcal disease
Two current available vaccines:Pneumococcal conjugate vaccine (PCV13)
Pneumococcal polysaccharide vaccine (PPSV23)
Pneumococcal Vaccine
PCV13 originally only approved for children, but in 2011 was approved for adults 50 years or older by the FDA
Studies showed that PCV 13 was 75% effective in protecting vaccinated individuals against invasive pneumococcal disease 45% effective against pneumococcal pneumonia
The PPSV23 protects 50-85% of vaccinated individuals with healthy immune systems against invasive pneumococcal disease
Pneumococcal Vaccinations
Adults who are immunocompetent and aged 65 years or older should receive 13-valent pneumococcal conjugate vaccine (PCV13) followed by 23-valent pneumococcal polysaccharide vaccine (PPSV23) at least 1 year after PCV13.
Current recommendations are that adults receive 1 dose of PCV13 and 1, 2, or 3 doses of PPSV23 depending on indication.
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Pneumococcal Vaccinations
When both PCV13 and PPSV23 are indicated, PCV13 should be administered first; PCV13 and PPSV23 should not be administered during the same visit.
If PPSV23 has previously been administered, PCV13 should be administered at least 1 year after PPSV23.
When two or more doses of PPSV23 are indicated, the interval between PPSV23 doses should be at least 5 years.
Pneumococcal Vaccinations
No additional doses of PPSV23 are indicated for adults who received PPSV23 at age 65 years or older.
When indicated, PCV13 and PPSV23 should be administered to adults whose pneumococcal vaccination history is incomplete or unknown.
References
Andreas F. Widmer, Reno Frei, Stefan Erb, Anne Stranden, Ed J. Kuijper, CornelisW. Knetsch, Sarah Tschudin-Sutter; Transmissibility of Clostridium difficile Without Contact Isolation: Results From a Prospective Observational Study With 451 Patients. Clin Infect Dis 2017; 64 (4): 393-400. doi: 10.1093/cid/ciw758
Bonten MJ, Huijts SM, Bolkenbaas M, et al. Polysaccharide conjugate vaccine against pneumococcal pneumonia in adults. N Engl J Med. 2015;372(12):1114–25.
Gardam, M.A., Amihod, B., Orenstein, P., Consolacion, N., & Miller, M.A. (1998). Overutilization of indwelling urinary catheters and the development of nosocomial urinary tract infections. Clinical Performance & Quality Health Care, 6(3), 99–102.
Garey KW, Ghantoji SS, Shah DN, Habib M, Arora V, Jiang ZD, DuPont HL. A randomized, double-blind, placebo-controlled pilot study to assess the ability of rifaximin to prevent recurrent diarrhoea in patients with Clostridium difficile infection. J Antimicrob Chemother.2011 Dec;66(12):2850-5. doi: 10.1093/jac/dkr377. Epub 2011 Sep 21.
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References Herpers BL, Vlaminckx B, Burkhardt O, Blom H, Biemond-Moeniralam
HS, Hornef M, Welte T, Kuijper EJ. Intravenous tigecycline as adjunctive or alternative therapy for severe refractory Clostridium difficile infection. ClinInfect Dis. 2009 Jun 15;48(12):1732-5. doi: 10.1086/599224.
Holly Keyt, Paola Faverio, and Marcos I. Restrepo. Prevention of ventilator-associated pneumonia in the intensive care unit: A review of the clinically relevant recent advancements. Indian J Med Res. 2014 Jun; 139(6): 814–821. PMCID: PMC4164993
Holroyd KB, Rittenberg A, Pahwa A. Misanalysis of UrinalysisA Teachable Moment. JAMA Intern Med. 2016;176(4):432-433. doi:10.1001/jamainternmed.2016.0067
Jain, P., Parada, J.P., David, A., & Smith, L.G. (1995). Overuse of the indwelling urinary tract catheter in hospitalized medical patients. Archives of InternalMedicine, 155(13), 1425–1429.
References Kalil AC, Metersky ML, Klompas M, Muscedere J, Sweeney DA, Palmer
LB, Napolitano LM, O'Grady NP, Bartlett JG, Carratalà J, El Solh AA, Ewig S, Fey PD, File TM Jr, Restrepo MI, Roberts JA, Waterer GW, Cruse P, Knight SL, Brozek JL. Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis.2016 Sep 1;63(5):e61-e111. doi: 10.1093/cid/ciw353. Epub 2016 Jul 14.
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