Infection Control C. Diff, MRSA, VRE

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Infection ControlC. Diff, MRSA, VRE

• Karyn Leible, RN, MD
• Chief clinical Officer Pinon Management
• Medical Director
• Colorado State Veterans Home, Fitzsimons

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483.65 Infection ControlF Tag 441

• F-Tag 441 (R) - Facility must
• establish and maintain an Infection Control
  Program
• provide a safe, sanitary, comfortable environment
  
• Help prevent development and transmission of
  disease and infection

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Diarrhea Outbreak

• Your facility has a significant diarrhea
  outbreak
• Your Inf Cntrl program is working (the medical
  director is supposed to be notified of possible
  outbreaks). The ICP calls to inform you that the
  facility has had 16 cases of diarrhea in the last
  two days. (No surprise, staff absenteeism is up
  too).
• Are there any recommendations to prevent spread
  you would like to make?

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Diarrhea outbreak

• The ICP reminds you that the facility was cited
  at the last survey for non-compliance with F-Tag
  444 - Handwashing F-Tag 444 is also under 483.65
  Infection Control
• You remember giving an inservice on handwashing
  as part of the Plan of Correction (POC)

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F-Tag 444 Hand washing

• ( R) The facility must require staff to wash
  their hands after each direct resident contact
  for which handwashing is indicated by accepted
  professional practice.
• (IG) Procedures must be followed to prevent cross
  contamination, including handwashing or changing
  gloves after providing personal care, or.
• IG) Facilities for hand washing must be available

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Case 2 Diarrhea outbreak

• You recommend isolation (remain in room, meals in
  room) for residents with diarrhea
• This is of course in addition to your ongoing
  universal precautions policy
• standard precautions
• Your social worker says you cant do that, it
  violates residents rights

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F-Tag 442 Preventing the spread of infection

• ( R ) When the infection control program
  determines that a resident needs isolation to
  prevent the spread of infection, the facility
  must isolate the resident
• ( IG ) Isolate appropriately to reduce the risk
  of transmission

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F-Tag 442 Preventing the spread of infection

• (IG) Isolate residents only to the degree needed
  to isolate the infecting organism
• (IG) Method should be the least restrictive
  possible while maintaining the integrity of the
  process

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Diarrhea outbreak

• This example is real
• In South Dakota between October 2, 2002 and
  January 8, 2003, 14 of 6093 residents became ill
  with acute gastrointestinal symptoms
• In the facility, 56 of residents had
  gastrointestinal symptoms within a 9 day period
  at the end of December 2002

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Diarrhea outbreak

• Investigation by the state health department
  strongly suggested that the majority of these
  cases were related to Norovirus infection
• This is the same virus implicated in diarrheal
  outbreaks on cruise ships

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Norovirus

• High attack rates (68 in one study)
• Can shed up to two weeks after sxs resolve
• Low infectious dose (lt 100 virons)
• High persistence of agent in the environment
• Potential for multiple modes of transmission
• Percentage cases with vomiting gt 50
• Absence of long-lasting immunity
• Outbreaks can involve multiple strains

www.cdc.gov/ncidod/dvrd/revb/gastro/norovirus-fact
sheet-htm
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Surveillance
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Infection ControlSurveillance Program

• Infections present on the residents admission or
  readmission, or that develop within 48 hours
  after admission, are NOT considered nosocomial
• 48 hours may not be long enough in the case of
  C. difficile, but regs and their necessarily
  arbitrary definitions cannot account for this
  outlier

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Infection ControlSurveillance Program

• It is important and useful to have precise
  definitions
• Be sure you know what definitions the ICP is
  utilizing
• Be sure the ICP is compulsive in adhering to
  definitions

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Infection ControlEpidemiological Definitions

• General rules
• A. Only NEW symptoms or acute changes in chronic
  symptoms should be considered
• B. Potential noninfectious causes of the
  symptoms and signs should always be considered
  before diagnosing infection
• C. Infection should be diagnosed based on
  several supporting data and not on a single
  finding. Microbiological and radiological
  findings should be used only to confirm clinical
  evidence of infection

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MDS Section I-2 asks about infections
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Infection Control

• Rates of infection
• Calculation of rates
• Review and trend monthly
• Watch for patterns, outbreaks
• Add your clinical knowledge to apparent
  statistical truth
• Review of antibiotic usage is often an easily
  obtained and useful adjunct to ICP generated
  statistical data

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Clostridium difficile

• Diagnostic Criteria
• Diarrhea
• Evidence of CDAD (c. diff associated diarrhea) by
  any of the following
• Positive assay
• Pseudomembranous colitis
• Positive stool culture

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Clostridium difficile

• Diagnostic Tests
• Cell Culture Cytotoxin Assay
• Stool Culture
• EIA

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Clostridium difficile

• Facts
• Leading cause of nosocomial enteric infection.
• 3 million new cases/year in U.S.
• 20 thousand new cases/year in U.S. outside
  hospital setting.

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C. DIFF.
C. DIFF.
C. DIFF.
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Clostridium difficile

• HEALTH CARE WORKER
• Rarely have fecal carriage.
• Carriage on stethoscopes, clothing and hands well
  documented.
• Hand washing/gloves proven to decrease rates of
  infection.
• One study, HCW hand culture rate was 59.

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Clostridium difficile

• PRIMARY PREVENTION
• Antibiotic Control
• Avoid antibiotic use.
• Limit duration.
• Antibiotics with and association
• Cephalosporins (keflex, rocephin)
• Clindamycin
• Floroquinalones (Cipro, Levoquin)

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Clostridium difficile

• PRIMARY PREVENTION
• Hand washing and gloves.
• Both proven to lower Clostridium difficile rates.
• Simple tasks but compliance low.
• Responsibility
• As your mother said WASH YOUR HANDS
• And use soap!

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Clostridium difficile

• PRIMARY PREVENTION
• What to wash with?
• Study liquid soap vs 4 chlorhexidine
• Without gloves no difference.
• With gloves liquid soap
• out-performed 4 chlorhexidine.
• Wash with soap
• Remember Mom says use soap!

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Clostridium difficile

• PRIMARY PREVENTION
• Cleaning the Long Term Care Facility
• Eliminate or reduce spores.
• Spores are widespread and can persist for
  weeks-months.
• Spores are resistant to most commonly used
  disinfectants.
• 110 bleach and water solution
• Cleaning reduces spore numbers.

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Clostridium difficile

• PRIMARY PREVENTION
• Cleaning the facility
• As bed occupancy increases, time for cleaning
  decreases.
• Frequent movement of patients from bed-to-bed.
• Readmissions of asymptomatic carriers.

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Clostridium difficile

• SECONDARY PREVENTION
• Hand washing/gloves.
• Gowns.
• Thorough cleaning of all contaminated and
  potentially contaminated surfaces.
• Isolation/private rooms (the greater the
  diarrhea, the greater the need).

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Clostridium difficile

• SECONDARY PREVENTION
• Room contamination rates (McFarland, 1989).
• C. diff. (-) patient 8
• C. diff. Asymptomatic carrier 29
• CDAD patient 49

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Clostridium difficile

• An outbreak is likely to be caused by the
  transmission of organisms by staff and a
  breakdown in the use of standard precautions.
• Therefore an intense education program for staff
  should ensue with rigorous supervision of
  handwashing and use of gloves and gowns.

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Resistant Organisms
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Resistant Organisms

• The admissions coordinator wants to admit a
  patient whose labs indicate MRSA is growing in
  the sputum. The ICP calls to see if this is ok
  and to ask what precautions, if any, will be
  necessary.

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Methicillin Resistant Staphylococcus aureus

• What we think we know about MRSA
• STAPHYLOCOCCUS AUREUS
• 40 of healthy adults colonized with SA, half of
  those with nasal colonization carry it on their
  hands
• 10-44 of NF residents may be colonized
• Half-life of colonization estimated to be 40
  months
• Eradication of colonization rarely indicated
• Re-colonization after treatment is stopped is
  common
• Tend to select for resistant organisms

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What we think we know about MRSA

• Colonization rate increases with
• Bedridden
• Feeding tube, urinary catheter
• Poor functional status
• Hospitalization within 6 months
• Fecal incontinence
• Wounds
• Dialysis

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What we think we know about MRSA

• Transmission
• Contaminated environmental surfaces NOT felt to
  play a big role
• Contact (person to person)
• Role of airborne spread unclear
• Medicated soaps or alcohol gels may remove SA
  from skin

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MRSA in Wounds

• Attempt to cohort with other MRSA residents
• Avoid non-MRSA roommates who have unhealed
  wounds, indwelling catheters, or are
  immunosuppressed
• If drainage can be contained in a dressing,
  resident may go out of room unless exhibiting
  behaviors likely to increase chance of
  transmission (e.g., picking at wound dressing,
  picking nose)

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MRSA in Urine

• MRSA in urine
• Cohort with other MRSA patients
• Avoid high risk roommates
• If continent, may leave room
• If incontinent, ICP and Medical Director should
  analyze whether isolation to room is necessary
  (usually not)

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Respiratory MRSA

• Active pneumonia or bronchitis
• Private room
• Standard surgical masks for all entering room
• Respiratory tract colonization without signs of
  infection
• Private room not necessary
• Cohort
• Avoid high risk roommates
• At first sign of acute exacerbation, re-evaluate
  need for respiratory (droplet) isolation

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MRSA

• Housekeeping standard practices appropriate
• Barriers
• Gloves should be used, wash hands after removing
  gloves
• Gown use if care activity likely to result in
  soiled clothing (i.e., gown not needed to take a
  temperature or give medication)
• Masks needed only if aerosolization likely
• Isolation carts likely to be helpful

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MRSA in LTC

• In LTC
• Infection rates
• (colonized 10/yr non colonized 2-4/yr)
• Colonization not clearly related to MRSA-induced
  morbidity
• Non-MRSA mortality in colonized residents is 2-3
  times higher than in non-colonized
• probably reflecting functional status and
  underlying disease

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MRSA Emerging issues

• Vancomycin Resistant Staphylococcus aureus
• One case reported from Detroit in 2002
• One case reported from Pennsylvania in 2003
• One case reported from New York in 2004
• (MMWR 4-23-2004)
• Many more since

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MRSA Guidelines

• Changes
• Hibliclens baths and mupirocin to nares no longer
  required during treatment of MRSA infection.
• Surveillance cultures and/or decolonization
  therapy should not be required for admission to a
  LTCF.

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MRSA Guidelines

• Outbreak
• Increase in number of MRSA cases or a cluster of
  new cases (facility dependent)
• Increase of 25
• 3 or more new healthcare associated cases
• Decolonization of residents with MRSA
• Only in consultation with medical director or
  infection control specialist.
• Decolonization of healthcare workers
• Only if linked to epidemic

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MRSA Guidelines

• Outbreak
• Surveillance cultures
• Skin breakdown, draining wounds, anterior nares
• Other affected sites
• Serial cultures weekly to document end of
  transmission
• Focus on involved unit, indiv at high risk for
  MRSA, roommates
• Remember only consider surveillance cultures in
  outbreak situations.

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Resistant Organisms

• What if the potential resident had a urine
  culture showing VRE? Would you approve
  admission?

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What we think we know about VRE

• ENTEROCOCCI, (E. faecalis E. faecium)
• normal inhabitants of the bowel
• often resistant to aminoglycosides
• when high resistance occurs to gentamycin and
  streptomycin, there is usually no reliably
  bactericidal regimen

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What we think we know about VRE

• Multiple genetic mechanisms for vancomycin
  resistance
• Vancomycin resistance has been demonstrated to
  transfer between VRE and Staph aureus, Listeria,
  and Strep pyogenes
• Death rates from VRE bacteremia may exceed 30

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What we think we know about VRE

• RISK FACTORS FOR COLONIZATION
• Recent treatment with oral or parenteral
  Vancomycin or cephalosporins
• Recent treatment with anti-anaerobic drugs
  (metronidazole, clindamycin, imipenem)
• Prolonged hospitalization
• Proximity to patient colonized by VRE (not
  clearly demonstrated in LTC)

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What we think we know about VRE

• RISK FACTORS FOR COLONIZATION
• Care by nurse who cares for another VRE patient
• Longer ICU stay
• Care in hospital with high VRE prevalence
• Contamination from inanimate objects
• Factors increasing environmental or skin
  contamination (e.g., diarrhea)

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What we think we know about VRE

• COLONIZATION
• Fecal VRE an important source of infection as
  well as nosocomial spread
• Skin colonization (even above the waist) is
  common
• Duration of colonization variable (up to years)

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Control Efforts for VRE

• Limit use of vancomycin
• Limit use of other antibiotics, especially
  cephalosporins
• Vigorous environmental cleaning
• Isolation
• Rarely eliminate VRE entirely from institution

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What we think we know about VRE

• CONTROL EFFORTS
• Consider medical director chart review of
  residents with orders for vancomycin, fosfomycin,
  quinupristin-dalfopristin and linezolid to ensure
  drug is truly indicated

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Inappropriate uses of Vancomycin

• Eradication of MRSA colonization
• Primary treatment of C. difficile colitis
• Prophylaxis for indwelling catheters
• Topical use for irrigation
• When cultures are negative for B-lactam resistant
  organisms
• When only 1 of multiple blood cxs for
  coagulase negative staphylococci

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Appropriate uses of Vancomycin

• Treatment of serious infections caused by
  beta-lactam resistant gram positive organisms
• Treatment of infections caused by gram positive
  organisms in patients with true beta-lactam
  allergy
• C. difficile colitis which is both severe and
  unresponsive to metronidazole

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VRE Control Efforts

• All enterococcus isolates should be tested for
  sensitivity to vancomycin
• Surveillance cultures for VRE are NOT indicated
  unless in epidemic situation, or high risk unit
  (vent unit, dialysis unit)
• Do stool or rectal swab culture on roommates of
  newly diagnosed VRE residents

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VRE Control Efforts

• Notify ambulance staff and receiving
  hospitals/clinics when VRE resident is being
  transferred
• Educate staff about VRE and facilitys VRE
  policies
• Monitor rates of VRE infection and compliance
  with policies

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VRE Control Efforts Isolation

• Private room or cohort with another VRE patient
  (controversial in LTC)
• Wear gloves when entering room of VRE resident
• Wear gown if substantial contact with resident or
  environmental surfaces is anticipated, if
  resident is incontinent, or resident has ostomy,
  diarrhea, or wound drainage

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VRE Control Efforts Isolation

• Devoted equipment in room
• Remove gloves immediately upon exiting room AND
  wash hands with soap and water
• Ensure clothing and hands dont contact
  environmental surfaces after removal of gloves
  and gown and handwashing

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VRE Control Efforts Isolation

• STOPPING VRE ISOLATION
• Primary site culture is negative x1 if site is
  normally sterile
• Primary site culture is negative x2 (at least 72
  hours apart) if site not normally sterile (e.g.,
  skin, bowel, sputum)
• Stool VRE cultures negative x3 (at least 72 hours
  apart)

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VRE Control Efforts Isolation

• SHEA ISOLATION RECOMMENDATIONS
• Limit resident transport to situations required
  for medical care transport with precautions
• Residents may travel out of room, assuming they
  are coherent (able to understand instructions
  about basic hygiene), continent of stool (or
  diapered to contain stool), and wearing clean
  clothing
• Room restrictions probably appropriate for
  residents with wound drainage not contained by a
  dressing, or those incontinent or having diarrhea

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Resistant Organisms in Non-Hospital Settings CDC
Guidance

• Standard and Contact precautions and consider
• Patient placement - Private room, if possible.
  (when not available, cohort). Another option is
  to place an infected patient with a patient who
  does not have risk factors for infection.
• Group activities Maintaining socialization and
  access to rehab is important. Infected or
  colonized patients should be permitted to
  participate in group meals and activities if
  draining wounds are covered, bodily fluids are
  contained, and the patients observe good hygienic
  practices

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Infection Control

• Infection Control - Parting Thoughts
• Get to know the facility ICP very well. Be sure
  this person is well-trained and trustworthy.
• Policies may seem boring, but they can really
  help people keep their wits and do the correct
  thing in a time of urgency or crisis

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Infection Control

• Infection Control - Parting Thoughts
• Guidelines may seem set in stone, but they change
  frequently. Develop a method to keep up with
  changes. Distinguish between proposed changes
  (which the administrator hears about and panics)
  and actual finalized changes (which, if enforced
  by regulation, must be accommodated)

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Infection Control

• Infection Control - Parting Thoughts
• Recognize not all guidelines are written with the
  realities of LTC in mind
• Sometimes the guidelines are enforced by
  regulation and you must make them work
• Sometimes logical thinking is permissible and
  adaptation is appropriate and acceptable

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QUESTIONS?
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PINON HOSPITALITY SUITE 515 TO 645