Presentazione di PowerPoint

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Strategies for infection control adopted in the
Italian CF Centers
Silvana Ballarin, RN Filippo Festini, RN
BA Carmen Loganes, RN on behalf of the Italian
Cystic Fibrosis Nurses Group
www.infermieri-fc.net Infermieri-fc_at_iol.it
Gruppo Infermieri del GIFC
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Although the way CF patients get in contact with
respiratory pathogens such as PA or BC, has not
been completely explained, healthcare settings
seem to play a role in determining the risk for
patients of contracting infection. Segregation,
reduction of overcrowding, behavioral rules for
caregivers and patients and other measures have
showed to be effective in reducing the risk, in
some cases.

• aims of the survey
• to evaluate the measures adopted by the Italian
  CF Centers to prevent and control infections
  sustained by respiratory pathogens in CF patients
• to provide data for a future possible Italian
  consensus on this issue

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materials and methods
Standardized questionnaire, sent to all 21
Regional centers (15 mixed, 3 adult, 3 pediatric)
and 7 local CF Services. 24 questions
Regional Centers Local Services
Torino C.pediatrico Livorno
Torino C.adulti Roma OPBG
Milano C. pediatrico Cerignola
Milano C. adulti Messina
Verona Catania
Trieste
Genova
Parma
Cesena
Firenze
Ancona
Gualdo Tadino
Napoli C. adulti
Potenza
Soverato
Palermo
results
Answers from 16 Regional Centers (11 mixed, 3
adult, 2 pediatric) and 5 local services. 3363
patients (88.9 of Italian CF population)
Results will be presented both as number of
Centers and as of patients followed
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7 Centers (51.7 pts) non-shared healthcare
setting 14 Centers (48.3 pts) healthcare
settings in common with other services and
diseases

• Airways culture is usually performed every 3
  months in 18 Centers. (1 Center less frequently,
  2 Centers more frequently).
• In 15 Centers (84.7 pts) all caregivers are
  aware of pathogens present in last culture of
  patients they are taking care of.
• 10 Centers (50.6) have a written protocol about
  the infection control issue.

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Respiratory pathogens found in the last sputum or
throat swab culture of patients
Pts n.
P.aeruginosa 1820 54.1
B. cepacia 216 6.4
multiresistant P. aeruginosa () 213 7.6
meticillin-resistant S. aureus 165 4.9
Percentages are not reciprocally exclusive.
() missing data from 5 Centers
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SEGREGATION POLICIES
Segregation with regard to B. Cepacia is
implemented in all Italian Centers
Types of segregation policies adopted
  Centers n. of pts
Only with regard to BC 2 13.7
with regard to BC and PA 3 7.5
with regard to BC, PA and multiresistant PA 2 10.7
with regard to BC, PA and MRSA 2 5.9
with regard to BC, multiresistant PA and MRSA 3 25.6
with regard to BC, PA, multiresistant PA and MRSA 9 36.4
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WHAT KIND OF SEGREGATION MEASURES ?
Ambulatory settings fixing visits in different
days according to airways colonization is a
segregation measure adopted in all Italian Centers
kind of segregation measures adopted
  Centers n. of pts
Only appointments in different days 5 11.5
Appointments in different days and use of different medical devices and equipment 8 45.1
Appointments in different days and use of different visiting rooms 2 19.3
Appointments in different days, use of different visiting rooms and use of different medical devices and equipment 6 20.1
Inpatient settings single room and bathroom in
all CF Centers, except one
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STAFF HYGIENIC PRACTICES
Frequent hands washing all Centers Hands
disinfection 13 Centers (73.5 of pts) Use of
disposable gowns and gloves (only for
assisting some types of pts i.e. with BC or
MRSA) 13 Centers (74.2 pts)
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REDUCTION OF ENVIRONMENTAL CONTAMINATION

• Measures to reduce the presence of pts
• in the waiting room
  16 Centers (63.1)
• Ventilation of visiting room daily 19 Centers
  
• after each examination 17 Centers
  (52.8)
• Disinfection of visiting rooms surfaces daily18
  Centers (93.2)
• after each
  examination 4 Centers (19.8)
• Daily disinfection of waiting rooms surfaces 18
  Centers (90)
• Disinfection of wash-basin siphons 11 Centers
  (69)
• Nebulisation of disinfectants in visiting rooms3
  Centers (7.9)
• No aerosolised therapy in the outpatient
  clinic12 Centers (51.4)
• No toys, books etc. in the waiting room15
  Centers (71.9)

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DISINFECTANTS
n. of Centers using each type of disinfectant for
each kind of substrate
Chlorine based Acetic Acid Poliphenol Ethanol Clorexidin others missing
Floors 12 1 4 4
Furniture 10 1 3 1 4 2
Medical devices 8 1 1 3 3 5
Bathrooms 15 1 1 1 2 2
Basin siphons 8 3
Toys 5 1 1 1 3 10
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SPIROMETRY TESTING
Measures adopted are wide-ranging, as they depend
on the type of device used Use of disposable
mouthpieces 19 Centers (89.2 of pts) Use of
antibacterial filters 18 Centers (84.5 of
pts) 1 Center disinfection of mouthpiece, not
disposable (missing data from 1 Center)
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RESPIRATORY PHYSIOTHERAPY EQUIPMENT
No shared physio equipment, only personal ones 14
Centers (50.2 of pts) Use of common physio
equipment after sterilisation 5 Centers Use of
common physio equipment after disinfection 2
Centers
Suggested disinfection at home Possible more
than one at the same time Amukine 12 Centers
(54.1 of pts) Acetic Acid 13 Centers (53.8 of
pts) Boiling (or steam) 5 Centers (27.6 of
pts) Vinegar 2 Centers
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AEROSOL THERAPY EQUIPMENT
No shared A.T. equipment, only personal ones 14
Centers (56.7 of pts) Use of common A.T.
equipment after sterilisation 3 Centers Use of
common A.T. equipment after disinfection 4 Centers
Suggested disinfection at home Possible more
than one at the same time Amukine 12 Centers
(54.1 of pts) Acetic Acid 13 Centers (53.8 of
pts) Boiling (or steam) 6 Centers (35.1 of
pts)
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ENVIRONMENTAL MICROBIOLOGIC SURVEILLANCE
Periodical cultures of specimens from the
environment of healthcare setting are performed
in 7 Centers (45.7 of pts). Occasional or
periodical cultures on staff members (hands etc.)
are performed in 5 Centers (43.1)
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BEHAVIOURAL RULES FOR PATIENTS
Informational material on infection control issue
for patients available in 10 Centers (57.4 of
pts)
Beahioural rules for pts strongly suggested or
mandatory in CF Centers (n. of Centers and of
pts)
Strongly Suggested Mandatory
Cover mouth nose while coughing with disposable tissue 4 (8.0) 3 (6.2)
Wash hands after coughing 7 (35.9) 2 (2.6)
Don't cough close to other people 5 (14.9) 9 (58.2)
Keep 1 meter distance from other people 5 (38.5) 4 (8.8)
Wear mask (in particular cases) 2 (7.1) 13 (71.1)
Wash hands entering and leaving Center 3 (28.5) 5 (10.3)
Don't share with other people objects which get in contact with mouth or nose 2 (6.2) 18 (88.9)
Don't share toys 5 (14.9) 8 (46.1)
Don't see other Cf individuals in everyday life 6 (22.4) 4 (20.5)
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DATA ANALISYS (1)
P.aeruginosa in last culture
OR 2.75 (CI95 2.37-3.19) ?2 plt0.001
B.cepacia in last culture
OR 1.46 (CI95 1.09-1.94) ?2 p0.007
Segregation with regard to PA seems effective in
determining a lower prevalence of PA
colonization. Is it effective in reducing
prevalence of BC colonisation too ?
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DATA ANALISYS (2)
OR 2.82 (CI95 2.1-3.79) ?2 plt0.001
Multiresistant P.aeruginosa in last culture
Data from 5 Centers missing ! Segregation with
regard to MR PA seems effective in determining a
lower prevalence of MR PA colonization.
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DATA ANALISYS (3)
OR 1.48 (CI95 1.06-2.07) ?2 p0.015
Meticillin resistant S.Aureus in last culture
Segregation with regard to MRSA seems effective
in determining a lower prevalence of MRSA
colonization.
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DATA ANALISYS (4)
No correlation between the prevalence of each
single pathogen in each CF Center and -
Number of patient followed by each Center -
Number of yearly visits performed in the
outpatient Clinic
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DATA ANALISYS (5)
Use of structures (premises, rooms, staff,
equipment etc) in common with other Services
which take care of different diseases
OR 1.96 (CI95 1.47-2.62) ?2 plt0.001
Multiresistant P.aeruginosa in last culture
Data from 5 Centers missing ! Is the use of
non-shared structures effective in reducing the
prevalence of MR PA? No significant differences
in prevalences of PA, BC and MRSA
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DATA ANALISYS (6)
Comparison with 2001 CFF Registry data Higher
prevalence of P.aeruginosa in USA than in
Italy (58.8 vs. 54.1, ?2 plt0.001) Higher
prevalence of B.cepacia in Italy than in
USA (6.4 vs.3.1, ?2 plt0.001)
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DISCUSSION (1)

• In general, policies and measures adopted by
  Italian Centers seem effective in controlling
  infections from respiratory pathogens in CF
  patients.
• Nonetheless in a few Centers some measures are
  still being used whose inefficacy has been proved
  (e.g. environmental nebulisation of disinfectant)
  or which put patients at serious risk of
  contamination (e.g. use of shared AT devices
  after simple disinfection).

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DISCUSSION (2)

• Many factors are involved in and concur to the
  prevention and control of infection from
  respiratory pathogens in CF
• Characteristics of the CF Centers structure
• Type of segregation policy adopted
• Measures of segregation adopted
• Protocolos of disinfection used
• Staff members hygienic practices
• Behavioural rules suggested to patients
• A local policy for infection control should
  consider as many factors as possible among the
  above mentioned, considering available resources.
• Many CF Centers staffs have complained of the
  shortage of structural, logistic and human
  resources available, which seems to be an
  important barrier to an effective infection
  control.

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SUGGESTIONS

• Adopt a written protocol for prevention and
  control of infections from respiratory pathogens,
  which takes into account the resources available
  locally.
• Provide that all staff members are aware of the
  airways microbiological status of the CF patients
  they are assisting.
• Consider the implementation of regular
  environmental microbiological controls.
• Program a Consensus on national guidelines about
  prevention and control of infections

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Italian Cystic Fibrosis Nurses Group
Gruppo Infermieri del GIFC
www.infermieri-fc.net
infermieri-fc_at_iol.it