Bad News – Good News: The Basics of Infection Prevention and Control

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Bad News Good NewsThe Basics of Infection
Prevention and Control

• July 2012
• Judith Conway, RN, BS, CIC
• Infection Control Coordinator
• Communicable Disease Control Section
• Office of Health Protection
• Illinois Department of Public Health
• E-mail judith.conway_at_illinois.gov
• Telephone [phone]

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Session Overview

• Fundamental information
• Germology terminology
• Antibiotic resistance 101
• Chain of infection routes of infectious disease
  transmission
• Brief review of basic infection
  prevention/control recommendations used to
  prevent transmission
• Problematic pathogens
• Scenarios

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Fundamental Information

• Its a bug-drug war
• Bug bacteria
• Drug antibiotic
• Bad news Some bacteria have become increasingly
  resistant to antibiotics
• Good news We can help prevent infectious disease
  transmission by understanding and applying basic
  infection prevention/control practices

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Antibiotic Resistant Germs

• Antibiotic resistance can travel the globe

Resistance anywhere is resistance everywhere
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Welcome to Your New Normal
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FUNdamental InformationPre-Assessment

• Antibiotics are drugs that fight infections
  caused by
• Bacteria
• Viruses
• Bacteria and viruses
• FILL IN THE BLANKS ____________ ___________ is
  the primary strategy recommended by CDC as the
  foundation to prevent transmission of infectious
  agents in all healthcare settings.
• TRUE or FALSE? MRSA is spread by airborne
  transmission.

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FUNdamental InformationPre-Assessment

• Antibiotic-resistant pathogens are most
  frequently spread from one patient to another in
  healthcare settings by
• Airborne spread resulting from patients coughing
  and sneezing
• Patients coming in contact with contaminated
  equipment
• The contaminated hands of healthcare workers
• Substandard environmental maintenance
• What is the IDPH recommendation for the length of
  time to perform proper hand washing?
• TRUE of FALSE? Clostridium difficile is readily
  killed by alcohol-based hand hygiene products.

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Is this a good thing or a bad thing?
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Germology TerminologyMicroorganisms

• Microorganisms bacteria, viruses, fungi,
  protozoa, helminths, rickettsia, prions
• Biologic agents capable of causing disease
• Also known as infectious agents or pathogens
• Commonly called germs or bugs
• NOTE In todays session, we will focus
  exclusively on bacteria

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Germology TerminologyInfection versus
Colonization

• Infection Bad news, bad news, bad news
• Bad news Youve got it (it bacteria X)
• Bad news Its making you sick (invading your
  tissues and cells)
• Bad news It can be spread to others
• Colonization Bad news, good news, bad news
• Bad news Youve got it (it bacteria X)
• Good news Its not making you sick
• Bad news It can be spread to others

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Antibiotic Resistance 101

• What are antibiotics?
• Drugs used to fight infections caused by bacteria
• It is important to remember that antibiotics have
  no effect on viruses
• How do antibiotics work?
• 2 main types of action
• Bacteriostatic inhibit bacterial growth
• Bactericidal kill bacteria

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Antibiotic Resistance 101

• What is antibiotic resistance?
• Ability of bacteria to resist the effects of an
  antibiotic
• How does it occur?
• Occurs when bacteria change in some way that
  reduces or eliminates the effectiveness of
  antibiotics
• Because the antibiotic isnt effective, the
  bacteria survive and continue to multiply and
  cause harm

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Antibiotic Resistance 101

• How do bacteria become resistant to antibiotics?
• Bacteria have several mechanisms
• Some bacteria develop the ability to neutralize
  the antibiotic
• Other bacteria rapidly pump out the antibiotic
• Still other bacteria change the antibiotic attack
  site (on the bacterial cell wall) so that the
  antibiotic cant do its work of affecting
  bacterial metabolism
• Additionally, some bacteria can transfer pieces
  of DNA that code for resistance to other bacteria

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Antibiotic Resistance 101

• What happens when bacteria become resistant to
  antibiotics?
• Selective pressure resistant bacteria survive,
  multiply, and replace all the sensitive
  (susceptible) bacteria that were killed off
• Just like antibiotic-susceptible bacteria,
  resistant bacteria can spread to other people and
  cause colonization or serious infections

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Antibiotic Resistance 101

• Why are bacteria becoming resistant to
  antibiotics?
• Antibiotic use promotes development of
  antibiotic-resistant bacteria
• Every time a person takes antibiotics, sensitive
  (susceptible) bacteria are killed, but resistant
  bacteria may be left to grow and multiply
• Overuse and misuse
• Antibiotics are not effective against viral
  infections

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Chain of Infection
Causative Agent
Susceptible Host
Reservoir
Portal of Exit
Portal of Entry
Mode of Transmission
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Chain of InfectionModes of Transmission

• Microorganisms are spread through 3 primary
  routes
• AIRBORNE
• DROPLET
• CONTACT
• Direct contact
• Indirect contact

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Airborne Spread

• Least common mode of transmission
• Dissemination of airborne droplet nuclei
  (small-particle residue 5 microns or smaller in
  size of evaporated droplets that contain the
  infectious pathogen and remain suspended in the
  air) or dust particles containing the infectious
  pathogen
• Examples of diseases spread through airborne
  transmission
• Anthrax spores from contaminated environment
• Chickenpox
• Disseminated herpes zoster (shingles)
• Measles (rubeola)
• Novel Strain Influenza airborne spread may
  occur, extent unknown
• Severe Acute Respiratory Syndrome (SARS)
• Smallpox
• Tuberculosis

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Droplet Spread

• Pathogen is spread in large respiratory droplets
  that dont stay suspended in the air they travel
  about 3 - 6 feet and then drop to the
  ground/surfaces
• Studies have shown that the nasal mucosa and
  conjunctivae (and, less frequently, the mouth)
  are susceptible portals of entry for respiratory
  viruses
• Examples of diseases spread through droplet
  transmission
• Influenza (seasonal influenza)
• Meningococcal Meningitis
• Mumps
• Pertussis (Whooping cough)
• Rubella (German measles)
• Severe Acute Respiratory Syndrome (SARS)

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Contact Spread

• Most common mode of transmission
• Direct contact germs (microorganisms) are
  transferred directly from one person to another
  person through physical contact
• Indirect contact transferred from contact with a
  contaminated item or contaminated hands
• Short list of examples of diseases spread through
  contact transmission
• Chickenpox
• C. diff
• Lice
• MRSA and other multidrug-resistant organisms
  (MDRO)
• Norovirus
• Scabies
• Smallpox

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Chain of InfectionPreventing Transmission

• CDC recommended these isolation precautions in
  1996
• Standard Precautions
• Transmission-based Precautions
• Airborne Precautions
• Droplet Precautions
• Contact Precautions

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Standard Precautions

• Primary strategy recommended by CDC as the
  foundation to prevent transmission of infectious
  agents in all healthcare settings
• Basic level of infection prevention/control
  practices to be used in the care of all patients
  at all times and in all healthcare settings,
  regardless of suspected or confirmed infection
• Intended to reduce the risk of transmission of
  bloodborne and other pathogens from recognized
  and unrecognized sources of infection
• Designed to both protect the healthcare worker
  and prevent the healthcare worker from spreading
  infections among patients

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Standard Precautions

• Five components of Standard Precautions
• Hand hygiene before and after touching a patient
• Personal protective equipment (PPE) (gloves,
  gowns, face protection masks, goggles, face
  shields) is used as indicated to prevent
  exposure to blood, body fluids, secretions, and
  excretions (except sweat), mucous membranes,
  non-intact skin, or contaminated equipment
• Safe injection practices (recommended in 2007)
• One Only campaign ONE needle, ONE syringe,
  ONLY ONE time
• Safe handling of potentially contaminated
  equipment or surfaces in the patient environment
• Respiratory hygiene/cough etiquette (recommended
  in 2007)
• Cover Your Cough

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Alcohol-Based Hand Hygiene Products

• Alcohol-based products are more effective for
  standard handwashing or hand antisepsis by
  healthcare workers (HCW) than soap or
  antimicrobial soaps In studies examining
  antibiotic-resistant organisms, alcohol-based
  products reduced the number of multidrug-resistant
  pathogens recovered from the hands of HCWs more
  effectively than did hand washing with soap and
  water.
• SOURCE CDC Hand Hygiene Guideline, 2002 page 11.

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Respiratory Hygiene/Cough Etiquette
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Who, What, Where, When, Why

• WHO On whom is the Precaution(s) used?
• WHAT What type of personal protective equipment
  is used by healthcare worker(s)?
• WHERE Where is the patient placed in the
  hospital or LTCF?
• WHEN When is the Precaution(s) used?
• WHY Why is the Precaution(s) used?

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Standard Precautions

• WHO All patients in all healthcare settings
• WHAT Hand hygiene and PPE healthcare workers
  have clean hands and use of appropriate personal
  protective equipment (gloves, gown, face
  protection) as indicated by the nature of the
  interaction and the extent of anticipated blood,
  body fluid etc. exposure
• WHERE No special room placement is required
• WHEN During all healthcare encounters
• WHY Prevent transmission of bloodborne and other
  pathogens from recognized and unrecognized
  sources of infection

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Airborne Precautions

• WHO Patient with known or suspected infection
  with airborne infectious agent
• WHAT Respirator and AIIR healthcare workers
  will wear respiratory protection (respirator)
  upon entry into patients Airborne Infection
  Isolation Room (AIIR)
• WHERE Airborne Infection Isolation Room (AIIR)
  patient is placed in a room with special air
  handling and ventilation capacity (negative air
  pressure)
• WHEN During hospitalization or LTCF stay while
  patient is known/suspected to be contagious
• WHY Prevent transmission of airborne infectious
  agents

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Droplet Precautions

• WHO Patient with known or suspected infection
  with droplet-spread infectious agent
• WHAT Mask healthcare workers will wear mask
  upon room entry / when working within 6 feet of
  patient
• WHERE Private room patient is placed in a
  private room, if available. Special air handling
  and ventilation capacity are NOT required or
  indicated.
• WHEN During hospitalization or LTCF stay while
  patient is known/suspected to be contagious
• WHY Prevent transmission of infectious agents
  spread through close respiratory or mucous
  membrane contact with infectious respiratory
  secretions

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Contact Precautions

• WHO Patient with known or suspected infection
  with contact-spread infectious agent
• WHAT Gown and gloves healthcare workers will
  wear gown and gloves for all interactions that
  involve contact with patient
• WHERE Private room patient is placed in a
  private room, if available. Special air handling
  and ventilation capacity are NOT required or
  indicated.
• WHEN During hospitalization or LTCF stay while
  patient is known/suspected to be contagious
• WHY Prevent transmission of infectious agents
  spread through direct or indirect contact

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How to Safely Don Remove PPE

• The addddddition of a mask for certain spinal
  procedures grew from recent evidence of an
  associated risk for developing meningitis caused
  by respiratroy flora
• The use of a mask when performing certain
  high-risk, prolonged procedures involving spinal
  canal punctures (e.g., myelography, epidural
  anesthesia)

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Problematic Pathogens
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Clostridium difficilea.k.a. C. diff

• Bacteria spore-forming bacteria
• Toxin-producer produces exotoxins (toxin A and
  toxin B) that are pathogenic to humans
• Exotoxins toxin A and toxin B
• Illness diarrhea (known as Clostridium difficile
  infection CDI)
• Can also cause serious intestinal conditions,
  sepsis
• CDC estimates that 14,000 deaths occur annually
  due to CDI

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Main Symptoms of CDI

• Watery diarrhea
• Fever
• Loss of appetite
• Nausea
• Abdominal pain/tenderness
• Public Health definition of diarrhea 3 or more
  loose stools within a 24-hour period

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Risk Factors for CDI

• Antibiotic exposure
• Proton pump inhibitors
• Gastrointestinal surgery/manipulation
• Long length of stay in healthcare settings
• Serious underlying illness
• Immunocompromising conditions
• Advanced age

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CDI New Difficulties With an Old Pathogen

• Nationwide, increased rates of CDI, with more
  severe disease and increased mortality
• Possible reasons include the emergence of a new
  strain of C. diff with increase virulence and/or
  antibiotic resistance
• New strain has increased production of toxins A
  and B, and can produce an additional toxin known
  as binary toxin

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CDI Healthcare Facility Infection Control

• Contact Precautions for patients with known or
  suspected CDI
• Soap water hand hygiene alcohol doesnt kill
  spores
• Continue Contact Precautions until diarrhea
  ceases and patient has been diarrhea-free for 3
  days
• Ensure adequate cleaning and disinfection of
  environmental surfaces, especially items likely
  to be contaminated with feces
• During outbreaks, use a bleach-based disinfectant
  or an EPA-registered disinfectant with a
  sporicidal claim

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Multidrug-Resistant Organisms

• Multidrug-resistant organisms (MDRO) are
  microorganisms, predominantly bacteria, that are
  resistant to 1 or more classes of antibiotics
• In some cases, the microorganisms have become so
  resistant that no available antibiotics are
  effective against them

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Facts About MDRO Transmission

• Transmitted by the same routes as antibiotic
  susceptible infectious agents
• Patient-to-patient MDRO transmission in
  healthcare settings is usually via contaminated
  hands of healthcare workers
• Contact Precautions are recommended to prevent
  MDRO transmission in healthcare settings

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MRSA in the 21st Century
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What is Staphylococcus aureus?

• Bacteria often referred to as Staph
• Carried on the skin or in the nose of healthy
  people
• Approximately 30 of the population carry it on
  the skin or in the nose
• Approximately 2 carry a type known as MRSA

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What Is MRSA?

• MRSA stands for Methicillin-Resistant
  Staphylococcus aureus
• It is a type of Staph bacteria that is resistant
  to certain antibiotics including penicillin,
  methicillin, and amoxicillin
• HA-MRSA stands for healthcare-associated MRSA
• CA-MRSA stands for community-associated MRSA

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MRSA Infection

• In the community, most MRSA infections are skin
  infections
• In healthcare settings, more severe or
  potentially life-threatening infections may occur
  among patients e.g., bloodstream infection,
  pneumonia, surgical site infection, urinary tract
  infection
• MRSA is spread by contact transmission

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ESBL-Producing Bacteria

• ESBL Extended-Spectrum Beta-Lactamase
• Beta-lactams are a class of antibiotics
• Beta-lactamase is an enzyme that deactivates the
  antibiotics
• ESBLs are enzymes that confer resistance to a
  broad (extended) spectrum of beta-lactam
  antibiotics third and fourth generation
  cephalasporins
• ESBL-producing bacteria have been identified in
  E. coli, and also in Klebsiella, Proteus,
  Pseudomonas, Salmonella, and Serratia species
• ESBL-producing bacteria are spread through
  contact transmission

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Carbapenem Resistance and Carbapenemase-Produci
ng Bacteria

• Carbapenems a class of beta-lactam antibiotics
  (imipenem, meropenem, ertapenem, doripenem)
• Carbapenems have been used as a last line of
  defense in treating infections caused by
  ESBL-producing bacteria
• Some bacteria have developed the ability to
  produce carbapenemase which is an enzyme that
  deactivates carbapenem antibiotics
• KPC refers to Klebsiella pneumoniae carbapenemase
• CRE refers to carbapenem-resistant
  Enterobacteriaceae
• KPC / CRE are spread through contact transmission

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Bad News

• Antibiotic resistance is one of the worlds most
  pressing public health threats
• Antibiotic overuse increases the development of
  drug-resistant germs
• It will be many years before new antibiotics are
  available to treat some resistant infections
• Klebsiella pneumoniae carbapenemase (KPC)
  infection -- a type of antibiotic resistant
  bacteria also known as CRE -- is found in 37
  states
• Resistance anywhere is resistance everywhere
• Antibiotic resistance can travel the globe
• (Information source CDC Web site Get Smart for
  Healthcare)

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CDC 2011 Location of CRE Caused by KPC Enzyme
CRE Caused by Other Enzymes Noted
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Good News

• Many healthcare facilities are making infection
  prevention a patient safety priority
• Implementation and correct adherence to Standard
  Precautions, and Contact Precautions when
  indicated, are low-tech practices that help
  prevent MDRO transmission
• CDC has launched educational programs and
  campaigns to promote the proper use of
  antimicrobial agents

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FUNdamental Information Knowledge Assessment

• Antibiotics are drugs that fight infections
  caused by
• Bacteria
• Viruses
• Bacteria and viruses
• BACTERIA.
• FILL IN THE BLANKS ________ _________ is the
  primary strategy recommended by CDC as the
  foundation to prevent transmission of infectious
  agents in all healthcare settings.
• Standard Precautions
• TRUE or FALSE? MRSA is spread by airborne
  transmission.
• FALSE MRSA is spread by contact transmission.

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FUNdamental InformationKnowledge Assessment

• Antibiotic-resistant pathogens are most
  frequently spread from one patient to another in
  healthcare settings by
• Airborne spread resulting from patients coughing
  and sneezing
• Patients coming in contact with contaminated
  equipment
• The contaminated hands of healthcare workers
• Substandard environmental maintenance
• The contaminated hands of healthcare workers
• 5) What is the IDPH recommendation for the length
  of time to perform proper hand washing? 20
  seconds of scrubbing
• 6) TRUE of FALSE? Clostridium difficile is
  readily killed by alcohol-based hand hygiene
  products. FALSE alcohol doesnt kill spores

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Is this a good thing or a bad thing?
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Is this a good thing or a bad thing?
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Is this a good thing or a bad thing?
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Is this a good thing or a bad thing?
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Is this a good thing or a bad thing?
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Is this a good thing or a bad thing? (Dont be
alarmed! This photo was staged its not really
blood!)
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Is this a good thing or a bad thing?
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Is this a good thing or a bad thing?
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Concluding Comments