MDRO transmission

There has been an increase in MDROs over the last decade. This can be related to the increaseing use of antibiotics, patient's exposure to the healthcare systems - especially in ICUs -invaisive procedures - things that are not normal to the body - and long term illnesses.








bacteria photo
MRSA
VRE
pseudamonas
stenomonophilia
acinetobacter
esbl e coli & klebsiella pna

C Diff -transmitted through oral-fecal route. C diff spores have been cultured out of rooms up to 40 days after a patient has left the room. Rooms should be cleaned with a 10% hypochlorite (bleach) solution.



gram negative rod picture

Creutzfeldt-Jacob disease
Is a prion disease. Prions do not have DNA and RNA. Prions are a protien, which present a unique IC challenges, because they are resistant to traditional chemical and physical contamination. All equipment used in the OR should be disposable, all equipment used for these patient throughout the hospital should be disposable. Prions are resistant to disinfection.
CDC guidelines are stringent when dealing with this disease. Even funeral directors have very stringent guidelines about burial. Apparently prions can survivie for years even in soil.

Blood borne pathogens

CDC - center for disease control and OSHA occupational safety and health administration
have established guidelines for how to deal with blood and bpody fluids. Standard precautions - treat all body fluids as they if they are infected.

Wear appropriate PPE (personal protective equipment) when working with all patients. Wear impermable gowns when water or fluid splashing may occur.

Immediate disposal of sharps in regulated waste containers which have a biohazard label on them.

Management of sharps disposal in all hospitals are Mass DPH, CDC and OSHA regulations.

All healthcare facilities have policies for dealing with hazardous spills. Special spill kits strategically placed on every floor. These supplies in these kits are specially designed to take care of a biohazard spill.

All hospitals report their sharp injuries yearly to the state they are in. In the state of Massachusetts , the DPH has a department that deals with sharp injuries. The MaDPH reviews needle/sharp injuries across all hospitals, to see if there is a commonality - certain needle/sharp products that cause more injuries than others. If there is a common needle or sharp product causes more injuries the state will contact the company and have a discussion with them.
Sometimes the state will find a better and safe product and then have discussions with each hospital who use these products.

Environmental Cleaning

Cleanaing is defined as a process of using friction, detergent, and water to remove organic debris. The process by which any organic debris can be removed. Cleaning can remove but UnotU kill microorganisms

Disinfection is aprocess that kills most microorganisms on inanimate surfaces, Disinfection destroys pathogens exceptions are bacterial spores or their toxins or vectors by direct exposure to chemical or physical means.




Types of disinfectants:
1. Alcohols -non corrosive but can be a fire hazard. A mixture of 70% alcohol is effective against a wide range of bacteria (hand sanitizers), Higher concentrations (80% ethanol +5% ispropanol) are needed to efffectively inactivate the lipid envelop of viruses such as HIV, Hepatitis B, Hepatitis C. It is only partially effective against hepatitist A. It is ineffective against fungal and bacterial spores.


2. Phenolics - similar to alcohols but have higher acidic concentration. Some phenolics are germicidal and are used in formulating disinfectants.
Oldest know phenolic is carbolic acid. Hexachloraphine was used as a germicidal agent until it's side effects were known.

3. Aldehydes - such as gluteraldehyde. They have a wide antimicrobial activity and sporicidal and fungicidal. They cause severe eye, nose, and throat, and lung irritation along with headaches, drowsiness, and dizziness. All these symptoms can lead to asthma with prolonged exposure.

4. oxidizing agents
sodium hypochlorite - bleach
hydrogen peroxide
iodine
ozone
lactic acid
potassium permangante

5. Quarternary ammonium compounds (quats) such as benzalkonium chloride. Some concentrations have low level disinfection. Typically quts do not exhibit efficay against difficult to kill bacteria, enveloped viruses, pathologic fungi, and mycobacterium.Psuedomonas is not killed by quat solutons.


Disinfecting surfaces.
Cleaning soultions should be prepared according to manufacturer's instructions. Employees should adhere to these instructions.
Cleaning mops and cloths should be microfibers. The grab onto more dust and dirt. Microfiber mops can endure 300 washings and weigh 2 lbs. Regular speghetti mops weight up to 10lbs.

Taking of the gloves: a less dogmatic approach to the use of contact precautions

Taking off the gloves: toward a less dogmatic approach to the use of contact isolation
by Kathryn Kirkland

This review looks at the benefits and harms of isolation as a public health measure and proposed a framework for considering under what circumstances contact precautions might be used.

According to SHEA's recommendation - individuals whpo are thought to pose an infectious threat to others are placed in private rooms, or cohorted with patient(s) with the same infection.
They are cared by healthcare workers wearing PPE. PPE includes masks, gown, and gloves.

Benefits are not for the individual patient but for the greater good of the other patients. But for the individual patient the contact isolation can be intimidating. It is restrictive to the patient. Isolation has the costs of all the supplies that are needed for gowns, gloves and face masks.

The author feels there are 3 ways patients acquire infections:
1. Directly through contact with other patients (more uncommon even in a shared room)
2. Indirectly through contaminated hands of a healthcare worker.
3. Indirectly through environmental items.

The author of this article does not like contact isolation and the ramifications of it.
Her articulation in this article does bring new thoughts to light.
Contact isolation does try to prevent the transmission of microorganisms from patient to patient (which is thought through the hands of healthcare workers or environemntal items (such a sygmomanometers, thermometers, and pulse oximitry).
But a patient's own flora can be oportunistic and cause and infection, isolation would not help them.
The author feels that even if patients are exposed to bacter, the bacteria "hang out" until the patient's defenses aredown, and infection occurs.

This author feels that contact isolation should be done on a case by case basis not by generalize screen of cultures specific for certain MDROs.
I do not agree with this. There are flaws in the screening process, there has to be a base for which a hospital needs to start to do surveillance on their patients.
Today in 2010, the potential for exposure to an MDRO bacteria that is resitant to all known antibiotics is greater than in 2009. ANd in my hospital the LTAC, the patients who have been exposed to the hospital system, antibotics, and invaisive procedures. In this specific population,the risk of exposure is so great that I do not have a problem with contact precautions.

In an ideal world, private rooms for every patient would get away from "isolation" mindset.
Some hospitals are new, but a lot are old. The older hospitals have been reovated. The renovation process until recent times did not include private rooms. Private rooms require more space.

The author even with the research has not thought through all the scenarios possible. She had not through through the scenario of CRE (carbapebem resitant enterobacteria). Which there are no current antibiotics to treat.

So although I respect the authors research anf view and cannot concur with her.

Occupational exposures to cleaning products

Environmental Health 2009,8:11
www.ehjournal.net/content//8/11

Characteristics of occupational exposures to cleaning products used for common cleaning tasks - apilot study of hositpal cleaners

Background: idetify cleaning agents that aggrevate asthma and respiratory issues, skin irritation and sensitization. Assess the potential for inhalation and dermal exposure.

Results of the study:
Ingredients of cleaning products
quats
glycol ethers
alcohol
ammonia
phenols

Description of cleaning tasks
preparation of cleaning solutions
floor cleaning tasks
window, mirror, and glass cleaning
bathroom cleaning tasks
floor finishing tasks (stripping, waxing, buffing)
patient room cleaning

Low exposure category: floor cleaning tasks
Medium exposure category: window, mirrow and glass cleaning, sink cleaning, counter cleaning and toilet bowl cleaning
High exposure category: "combination tasks" patient and bathroom cleaning tasks, floor finishing

Conclusion: Cleaning products area a mixture of many chemical ingredients.
Exposures are a function of product formulation and product use.

MMWR Weekly CDC March 20, 2009 / 58(10;256-260)

Guidance for the control of infections with carbapene-resistant or carbapenmase producing enterobacteriaciea in Acute care facilities

CPC infections are currently challenging situtation in health care facilities.
CPC has been associated with high morbidity and mortality, and increased hospital stays therefore increased hospital costs.

Associated with prolonged hospitalizations are those patients who have been exposed to ICU environments, invaisive procedures (ventilators, central intravenous lines, NG tubes).This also increases a patient for a higher risk for HAI.

This is another concern that has developed for antimicrobial resistance. CPC and CRE have develop resistance to most known antibiotics today. An

And there are no first line antibiotics to treat these infections.


Samra Z, Ofir
Lashzinsky, Y
Shapiro, L

outbreak of resistant Klebsiella pneumonia producing KPC-3 in a teriary medical center in Isreal.

Int J Animicrobial Agents 2007; 30:525---9

when the outbreak occured in Insreal they separate out the infected patients.
They had a dedicated floor, equipment, and staff to care for the patients.
Surveillance was done on all the patients in the hospitals. All patients were isolated to a couple of floors.
It took about 2 weeks before the hospital had no new cases of KPC.

Antimicrobials go molecular

Antimicrobials go molecular: an update of the latest technology
by Kelly M Pyrek
editor in chief of Infection Control Today
February 2010 Vol 14 N02 p 8-18

Look at the antimicrobial movement at the molecular level

Lysozyme: surfaces that are hosptile to bacteria and viruses. Many antimicrobials are being incorporated (engineered) into non-porous surfaces. Lysozome is found in egg white as well as human tears and other secretions.

Lysozomes (muramidases) have the ability to damage cell walls of bacteria.It is naturally occuringStudies have shown that exposing staph aureus to lysozyme surfaces. SA adhered to those surfaces.
It is currently used in a mouthwash.(kills bacterial etc in the biofilm).

Silver




used as a coating on medical products. Silver ions are among the most potent antimicrobial agents.Silver and fulfur create an extremetly strong bond. Several enzymes involved witht eh metabolism of bacteria. ALthough overuse can lead to resistance, stewardship is the key.

Copper


copper's antimicrobial properties are only begining to gain acceptance with the science community.The EPA has approved registration of cooper alloys with the claims that copper is capable of killing bacteria. The EPA has an independent lab testing that it kills specififc bacteria such as MRSA. Noyce et al 2004 showed that 99.9% of MRSA arekilled in 2 hours at room temperature. Copper allloys can be usedon frequently touched surfaces such as counters, door knobs, bed rails, IV stands.

Textiles and microfibers

antimicrobials that have been woven into textiles
Micrillon texnology is the first embedded rechargeable broad-spectrum antimicrobial that is effective against bacteria, viruses, and fungi.


But still the author stresses that all of the abouve products need to be used in conjunction with already eatablished IC procedures such as HH, PPE, enivronemental cleaning.

Colonization of Gram negative MDRO among hospitalized patients

Infection Control and Hospital Epidemiology April 2010 Vol 31, No 3 pages 330-337 by
Amy Weintraub,MD
Mollie Roediger,MS
Melissa Barber, MLT
Amy Summers,BS
Ann M. Fieberg,MS
James Dunn, RN
Venus Seldon, RN
Fluryanne Leach,MS
Xio-Zhe Huang, PhDMikeljon P. Nikolich, PhD
Glenn Wortmann,MD

Natural History of Colonization with Gram Negative MDRO among Hospitalized Patients

This study was to determine the anatomical sites of colonization of gram negative MDROs
This study was done at Walter Reed Army Hospital with deployed patients.

Common infection is acinetobacter from Iraq

Groin was the best site for gnmdro
perirectal and groin areas were the best site for esbl e coli

A prolonged study showed that colonization persisted with gnbacteria.

Carbepenem use was censored in this study. Its use was associated with an increased rate of esbl e coli.

Spontaneous decolonization is rare.


Infection Control and Hospital Epidemiology April 2010 Vol 31 No 4 pages 338-340

Lisa Maragakis,MD, MPH
Trish Perl, MD, MSc.

Commentary: How can we stem the rising tide of Multi-resistant gram negatie bacilli?

There is evidence that gram negative bacilli are an emerging threat in healthcare institutions.
We have extensive knowledge of MRSA and VRE. We have less knowledge about gram negative resistant orgs.

The Healthcare Infection Control ADvisory Committee's Management of Multi-drug Resistant Organisms in Health Care Settings
by JD Seigel
E Rhinhart
M Jackson
L Chairello

Healthcare Infection Control Practices Advisory Committee. Management of Multi drug reistant organisms in healthcare settings. 2006 http://www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf accessed April 5, 2010


This article describes a 2 tier level of interventions to prevent and respond to transmission of MDRO in healthcare settings.
The 2nd tier included intensified surveillance culture to identify those patients who are colonized.

In the article by Weintraub et al they have described anatomical sites beneficial to get accurate culturing.Colonizers tended to last about 2 months or longer with gram neg resistant bacilli.

large groups of patients are not identified by the use of clinical cultures, only by the use of surveillance cultures. These unidentified colonized patients provide a resevoir for potentially transmission to other patients.

Weintraub et al have described certain sites for gran neg bacilli, and there are other identified culture sites for MRSA and VRE. To do all these surveillance cutlures on each patient would put a big burden on the microbiology lab.

But miltary setting aside, Weintraub et al have shown that the hospital is the primary setting for MDRo transmission. Selected pateint groups should be cultured: those who havebeen recently hospitalized and specific populations such as military returning from deployment.

More data is needed before we plunge into large scale surveillance , which could direct resources from other important infection prevention practices.

Misinformation on the social netweork in regards to infections and antibiotics

Misinformation about antibiotics can travel to large audiences via twitter: study

"Dissemination of health information theough social networks: Twitter and antibiotics,"
by Daniel Scanfeld, MS,MA
Vanessa Scanfeld, MPP
Elaine Larson, RN, PhD, FAAN, CIC
appeared in the AMerican Journal of Infection Control, vol 38 Issue 3April 2010 published by Elsevier



Twitter site was used to asnlyize 52,153 updates which mentioned antibiotics between March 13, 2009 and July 31, 2009.

Tweets were categorized into 11 categories:
1. general use. Most common category. Ranged from updates about antibiotics, days needed to be on antibiotics, and how long before they start to work
2. advise/information. 2nd common transfer of personal advice and information
3. side effects/negative reactions. 3rd common . General comments about how antibiotics made them feel to not being able to drink alcohol or sun sensitivity.
4. diagnosis
5. resistance
6. misunderstanding or misuse. This compromised 700 of the 52,000 tweets. These could spread to large audiences.
7. positive reactions
8. animals
9. wanting and needing
10. cost
11 other

This review of Twitter shows that misinformation can be disseminated to quickly and to thousands of people.
Tjis study showed that social media sites need to be monitored contantly and explore wayshow they can positively impact public health.

Targeting Zero

A philosophy that every healthcare institution should be working toward a goal of zero healthcare acquired infections.
It is understood that not all HAIs (hosital acquired infections) are preventable.

APIC (association for Professionals in infection control) ofers many courses, webinars, and guidelines how to study and track HAIs.

The importance of surveillance with HAIs cannot be emphasized enough.
There are manual systems and computer generated systems.
I personally work on the manual system. My company which has many hospitals does not
have in place a computer generated infection control surveillance.
My hospital has an electronic medical record. Radiology, pharmacy, nursing, medicine, and
rehab are all included in this record. The lab system is an independent computer
system.

By manually collecting data one must:
check lab workdaily
correlate antibiotic therapy to labwork
count IV and PICC line days and number of patients and calulate out
count foley catheter patients and foley catheter days and calculate out
manually watch HH and PPE and calculate satistics
make sure every patient admitted to the hospital has lab work to allow for continuity
of care


It takes a team to target zero. Everyone who takes care of a patient is included. From
the dietary aide to nurses aide, to nurse, and physician.

MRSA methacillin resistant staph aureus

VRE vancomycin resistant enterococcus

MDRO multi drug resistent organism - resistant to 1 or more classses of antibiotics

HH hand hygien

PPE personal protective equipment

SSI surgical site infection

CaUTI foley catheter urinary tract infection

BSI: blood stream infection

VAP: ventilator acquired infection

AORN association of operating room nurses

APIC Association of professionals in infection control

CDC center for disease control

esbl extended spectrum beta lactimase

CABSI catheter associated bloodstream infection

KPC carbepenem resistant enterococcus

E Coli - escherichia coli

C Diff clostridium difficile

STAC short term acute care facility - acute hospital

LTAC - long term acute care

JC Joint commission

PICC peripheraly inserted central catheter

pseudo - pseudamonas aeruginosa

VISA vancomycin intermediate sensitive enterococcus

MSSA methacillin sensitive staph aureus

SNIF skilled nursing facility (nursing home, rehabillitation center)

IP infection preventionist

CHG chlorhexidine gluconate

CMS centers for medicare and medicaid services

HAI healthcare associated infection

CAI community acquired infection

ISDA Infectious Disease Society of AMerica

SHEA Society for HEalthcare Epidemiology of America

NHSN National Healthcare Safety Network

CVC Central venous catheter

AVA Association of vascular access

CABG coronary artery bypass graft

SCIP Surgical Care Inprovement Project

OR operating room

SPD Sterile processing department

WHO world health organization

CPC

enterobacteria resistance to the class of antibiotics called carbepenems

Who are enterobacteriaceae?

Large group of gram negative rods that inhabit human large intestine, soil, plants, and water.
They grow equally well in air (aerobic) and without air (anerobic).
Most common enterobacteri that are found in hospitalized patients and causing disease are:
eschericia coli, Enterobacter cloacae, Klebsiella pneumonia, Serratia marcesens, and roteus mirailis.

Enterobacteriacae rarely infect patients that are not immunocompromised. Which means the host defenses must be breached in order to cause infection therefore illness.
How does this occur? surgery, IVs, tube feedings, burns, ulcers, breaks in the skin, and contaminated food or beverages.

Enterobacteriacae can be resistant to first generation cephalosporins such as cefazolin and cephalexin. Cephalosporins work by killing bacterial cells by imparie cell wall synthesis. This is done by preventing the cross-binding of the peptoglycan polymers neecessary for cell wall formtion. The most comon form of antibiotic resistance from enterobacteria are the production of beta lactimase which can destroy the beta lactam ring by hydrolysis therefore prevent antimicrobial activity. Theses are known as the ESBL's.

They are a common source of infections in the hospitalized patient. Repeated use of antibiotic drug specific to the infection, and empirical Use before culutres are done) use have cause these enterobacteriaceae in some patients to become very resistant to treatment.

What are carbepenems?
They interfere with cell wall synthesis by pinding to penicillin-binding proteins (PBPs) enzymes which are essential for cell wall synthesis

Spectrum of activity;
It is due to the PBPs of bothe gram negative and gram positive bacteria.

Carbepenes are: Imipenem, merepenem, ertapenem

Why is there a concern with this class of medications?
Enterobacteriaceae are now becoming resistant to this class of drugs.
This is our last line of defense against infections in some patients. There is no other treatment.

Pharmaceutical companies are not investing time and money into antibiotics becasue resistance occurs faster than drugs are worked on.

So how to we prevent the spread of these resitant enterobacteriaceae?

Hand hygiene.

Contact precautions

Dr. Carnelli from Tel Aviv Hospital, Tel Aviv, Isreal is an epidemiologist working their. They had an outbreak several year ago. He had 2 patient floors set aside for CPC patient. He halso had dedicated staff to those floors . Which means the staff did not work anywhere else in the hosptal. Equipment did not leave the floor. There were special exceptions: such as the patient who needed ICU care. It took about 2 weeks for nonew cases of CPC to develop. (The did genotyping on all the CPC detected). The hospital remained CPC free for about 6 months. Dr, Carnelli then looked at where the patients were coming from. Those patients coming from skilled facilities where their exposure to the healthcare system was higher, had a high incidence of CPC. Therefore every patient entering Tel Aviv hospital is now screened for CPC.

At the kindred hospital where I work and our sister site, patient who develop CPC are placed in a private room, with very strict precautions.



web sites visitied for this article:

Http//:emergency.cdc.gov/cocoa/summaries/pdf/CarbepenemResistantEnterobac1709.interim.pdf
Htt//:www.aic.cuhk.edu.hk/web8/carbepenems.htm
http//:lib.bioinfo.pl/meid.23481

Kindred Hospital Antibiotic Stewardship Program

APIC Text for Infection Control: Volume II Scientific and Practice Elements

Yehuda Carmeli,MD, MPH, Chief of Epidemiology Tel AViv Sourasky Medical Center Tel Aviv, Israel, Research staff member Beth Israel Deaconess Medical Center,Boston, Ma lecture given 3/15/2010

Kenneth Lawrence, PharmD
Clinical Pharmacy Specialist - Infectious Diseases, Tufts Medical Center, Boston, Ma
Assistant Professor of MEdicine, Tufts University School of Medicine, Boston, Ma lecture given 3/15/2010

Antibiotic-Resistant Bugs in the 21st Century - A Clinical SUper-Challenge. New ENgland Journal of Medicine 360;5 January 29, 2009 pages 439-443
by Cesar Arias, MD, PhD, and Barbara Murray, MD

Environmental Hygiene

4th Annual Infection Control Today; Virtual Conference on Professional Deveoplment
February 9-10, 2010
Department of HEalth and Human Servic es: CDC: MMWR (Morbidity and Mortality Weekly)
June 6, 2003/ Volume 52/ No. RR-10

There is a correlation between the hospital environment and hospital acquired infections. Enironmental services(ES), housekeeping.

Must understand disease transmision; droplet, airborne, fomite, vector

Organisms in the environment: MRSA, VRE, C Diff, serratia, pseudamonas, staph aureus, strep

Idenify patients on admission.

Cleaning a hospital room: needs 10 minutes for cleaning solutions and contact time
also have to consider all posible high touch areas - bedside table, light switches,
overbed table, remote control and call bell, door knobs; electronic media equipment


see CDC website for picture of Hospital room with terminal clean that cultured positive.


Have to know if C diff has been in the environment, need to use -10 bleach solution.

Products: Phenols, quats, bleach pay attention to exact measurments


Housekeeping - environemental services - much feel a apart of the hospital team. Need the correct tools. Right education and orientation to the hospital environment. Need respect and connection to purpose.

Best Practices in the Sterile Processing Department (STP)

4th annual conference from Infection Control Today: Virtual Conference of Professional Development
Febray 9-10, 2010

Best Practices in the Sterile Processing Department (STP) by Nancy Chobin, RN, AAS< CSPDM


Guidelines from AAMI and AORN

STP was always the department that was not thought of. Today it is a major player in the hospital.

STP scrubs; physical barriers to this department. Controlled temperature 60-65oF and humidity controlled between 30-60%; and a negative pressure room with less than 10 air exchanges/hour.

clean equipment with reusable brushes; correct detergent or enzymatic cleaner - measure amounts correctly.

Regulatory agencies AAMI and AORN require weekly testing for effectiveness

This inistial cleaning is to reduce biofilm formations and debris left after decontamination

Have to know the water quality and temperature. The correct temperature needs to be used with enzymatic cleaners. If the temperature is too high the enzymatic detergent can be killed, if the temperature is too low the enzymatic detergents can be slo=uggish.

Standard Precautions used in the SPD. Need water repellent gowns and gloves.

Must know how to load sterilizers for optimal cleaning. Each pack has an expiration date on the outside of the package. One time use products should never be cleaned and reused.

Sterilization: steam must contact all surfaces in the packged equipment.
there are special cycles be aware of those peices of equipment that require this.

Ethelene oxide gas: minimal heat and aeration time

There are now infrared thermometer guns check the temperatures on packages.

Storage of sterilized equipment: 2" from outside wall; 8-10" from floor; 18" from ceiling

Process improvement: monitor compliance; PPE use; hand hygiene; loading sterilizers; packaging audits; audit of cleaning and sterilization cycles

There should be good communication between the SPD, OR, and the infection preventionist.



First always process equipment according to the manufacture's instructions for cleaning

BSI realated information

AJIC (American Journal of Infection Control)
March 2010 Volume 38 Number 2, pages 149 - 153

PICCAs (Peripherally Inserted Venous catheters) are a safe alternative to high-risk short term CVC (centrally insered vebous catheters).

Authors: B Rait,MD;M Fakih,MD MPH; N Bryan-Nomides, MT MS; D Hopfner, RN; E Riegel, RN; Trudy Nenninger,RN; J Rey, MT(ASCP);S Szpunar,PhD; Detroit, Michigan


Background: PICCs serveas an alternative to short term CVC for provining IV access in the hospital setting. It is not clear which device has a lower risk of CLABSI( Central line associated blood stream infection). Comparision was made between PICC and CVC related CLABSI rates.


Results: 638 cvc were placed for a total of 4917 catheter days, of which 12 patients had CLABSI for a rate of 2.4/1000 catheter days (12 divided by 4917 x 1000)

A total of 622 PICCs placed for a total of 5703 catheter days of which 13 patients had CLABSI for a rate of 2.5/1000 catheter days (13 divided by 5703 x 1000)

The median time for a patient to develop a CLABSI with a PICC was significantly longer 23 days vs 13 fo CVC

Conclusion: the infection rate with PICCsand CVCs was about the same, but the length pof time for a CLABSI to develop was almost doubled. Therefor a PICC may be a better and safe choice for prolonged inpatient IV access.

Effectivenes of antibiotic use

APIC February 2010 Volume 38 Number 1, pages 38 -43

Effectivenss of drug use evaluation and antibiotic authoriation on patient's clinical outcomes, antibiotic consumption, and antibiotic expenditures

authors: P Rattanaumpawan, P Sutha, V Thamlikitkul (Bangkok, Thailand)

Background: zosyn,imipenem, and merepenem were inappropriately used in 50% of hosptialized patients. Hospital administrators implemented drug use evaluation (DUE) and antibiotic authorization for the abpove mentioned antibiotics beginning AUgust 2007. The objective of the study was to determine the effectiveness of antibiotic authorization on patient's clinical outcomes, antibiotic consumption, and antibioitc expenditures

Results: The patients who received antibiotic authorization had more favorable clinical outcomes (68.9% vs 60.5%) shorter duration of target antibiotics (7.5 days vs 9.3 days)
and lower mortality because of infections (29.4% vs 35.4%) than those who did not receive antibiotic authorization.

The costs of target antibiotics and all antibiotics in the authorization group were much less than those in the no-authorization group. The annual antibiotic cost savings from DUE can be figured out to $862,704.00

Conclusion: DUE and antibiotic authorization are effective strategies in reducing antibiotic consumption and expenditures, without compromising patient outcomes.

MRSA

NPR Fresh Air aired March 23, 2010

Host Terri Gross hosted author Maryn McKEnna

She wrote the book: The Fatal Menance of MRSA

Discussion of her research and findings on MRSA in hospitals and in the community

prevent antibiotic resistance

12 steps to prevent hospitalized adults

Prevent Infection

vaccinate hospitalized adults

get the devices out:

foley catheters, lines of all kinds - peripoheral IVs, invaisive lines - alines, swans, central

lines, triple lumens,PICCs, dialysis catheters; feeding tubes; tracheosotomy tubes

Diagnose and Treat Infections Effectively

Use appropirate methods for diagnosis

Target the pathogens - if UTI treat with oral agents for 3-5 days

BSI IV route better

Acess the experts:ID consults

Use Antimicrobials Wisely

Practice antimicrobial control - judiciously use antibiotics for appropirate infections not

colonizations

Use local data - antibiograms show with microbes are problems in your hospital

Treat infection, not contamination or colonization

Stop treatment: emperic antibitotic treatment should be reevaluated in 3 days to continue

or stop

Prevent transmission

Practice infection control - appropirate cohorting if need be

private rooms

isolate out MDROs from general hospital population

Practice hand hygiene and personal protective equipment (PPE)

Wash hands, wash hands, wash hands - cannot be said enough

PPE - appropirate to care - to prevent staff from transmitting microbes to other

patients and staff.

Equipment disinfection - prevent microbe spread

Hsopital room cleaning

APIC National Conference 2009

5 days worth of seminars

I attened many for a total of 37 CEUs

some included Contact Isolation Precautions: Burdens and Benefit
Joint Commission issues on NPSG related to IC practices
Keynote speaker Ben Carson,MD pediatric neurosurgeon, John's Hopkins

Targeting ZERO: The IP as a change agent

MDROs

Meeting of the Long Term Acute Care IPs and what are the issues facing this unique hospital setting

Device related Infections

Drug resistant TB

How to write an abstract for a peer reviewed publication

Course to study for the certification in fection control

APIC Premier CD

Core Measures of Performance
cost of care
mortality ration
patient experience
harm avoidance
evidence based care

Quality connect
challenges facing transparency and public reporting
regulatory mandates
physician engagement
patient safetyharm avoidance, HACs

Labor Connect
Labor challenges
Labor and staffing expenses
borrowing costs
bad debt
productivity levels
turnover rates

Safety Connect
patient safety, harm avoidance, HACs
transparency and public reporting
regulatory mandates
physician concern
legal uncertanties
An integrated approach to infection prevention


Resource Library

many resources to search on the web for further research

GE Healthcare 2009 Educational Services CD

Forum format 6 guest speakers each speaking on a different aspect of Infection Control/Prevention


MRSA BSI dramitc rise if MRSA esp in ICUs esp abcess and cellulitis
2000 NNIS stats shpow MRSA antibiotic resistance static rate
staph aureus MRSA rose from 37% -64% Most MRSA was non Beta lactam resistant

Community MRSA
non Beta lactam suseptible
novel chromosomal cassette SCCMEC Type IV
dermonecrotic crytotoxin PVL
strain USA 300
25% cause cellulitis and some bacteremias

Hospital MRSA
Resistant to non beta lactams
chromosomal cassett SCCMEC type II
infrequently encoded cytotoxin
multiple strains
predominate cause is bacteremias not cellulitis


MRSA
higher mortality
greater length of stay overall in hospital
increased costs for MRSA infection vs non MRSA infection $10,000 - $50,000 costs

where is MRSA found in patieents
colonized/respiratory tract 62%
soft tissue 18%
bone/joint 10%
catheter 1%
blood 11%
other 8%

MRSA is due to spread from a few clones
increasing incidence of MRSA suggests failure of infection prevention practices
Main goal is to prevent coloni will prevent infectionszation of non-colonized individuals

What is a LTAC?

What is an LTAC?

"www.kindredhealthcare.com/what-we-do/ltac/"
according to Kindred Hospital Corporate web site

Their LTACs provide specialized aggressive interdisciplinary care to medically complex patients who required extended recovery time. These patients are ill and have few options left, they come to Kindred because they requiure the aggessive and specialized care and prolonged recovery time that short term acute care hospitals cannot provide or are equipped to handle.

Infection ControlResearch

Guidelines to BSI
MMR August 9. 2002

APIC Elimination Guide to CRBSI

definitions of lines monitored

reulatory agencies and their benchmarks

pathophysiology and epidemiology od CRBSIs


insertion technique
evalutate daily for line need
remove when not needed
protocal dressing changes at site or prn


ways to calculate line days: line days divided by number of BSI x 1000= BSI per 1000 patient days calculated through the hospital system and benchmarked as such


how do look at the microbiology reports to evaluate colonization vs infected

quality look at how to improve statistics and decrease BSI rates.


credible source: one of the 3-5 regulatory agencies that are meeting the week of March 18-22, 2010 in Altanta, Ga. meeting is 5th Deceenial.

Along with ISDA, SHEA, CDC, APIC,

The WHO on Clean Hands Save Lives

There are 5 moments/opportunities for Hand Hygiene
1.Before touhing a patient
2.Before clean/aseptic techique
3. Afterbody fluid exposure/risk
4.After touching a patient
5.After touching a patient's surroundings

http://who.int/gpsc/5may/background/5moments/en/index.htmlClean care is Safe Care


Protecting 5million lives from harm Institute for Healthcare Improvement





Best practice: one individual item than improve patient outcomes

Bundles: A group of best practices that when used together provide better outcomes than when done alone






Plan act do study

initial

Infection control in changing health care system by WIlliam Jarvis
Emerging Infectious Disease CDC