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.