1. Bad News – Good News: The 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
Telephone: 217/

2. 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

3. Fundamental Information
It’s 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

4. Antibiotic Resistant Germs
Antibiotic resistance can travel the globe
“Resistance anywhere is resistance everywhere”

5. Welcome to Your New Normal…

6. FUNdamental Information: Pre-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.

7. FUNdamental Information: Pre-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.

8. Is this a good thing or a bad thing?
SBF

9. “Germology Terminology” Microorganisms
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 today’s session, we will focus exclusively on bacteria

10. “Germology Terminology” Infection versus Colonization
Infection: Bad news, bad news, bad news
Bad news: You’ve got it (it = bacteria “X”)
Bad news: It’s making you sick (invading your tissues and cells)
Bad news: It can be spread to others
Colonization: Bad news, good news, bad news
Good news: It’s not making you sick

11. 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

12. 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 isn’t effective, the bacteria survive and continue to multiply and cause harm

13. 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 can’t do its work of affecting bacterial metabolism
Additionally, some bacteria can transfer pieces of DNA that code for resistance to other bacteria

14. 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

15. 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

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

17. Chain of Infection: Modes of Transmission
Microorganisms are spread through 3 primary routes:
AIRBORNE
DROPLET
CONTACT
Direct contact
Indirect contact

18. 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

19. Droplet Spread
Pathogen is spread in large respiratory droplets that don’t stay suspended in the air; they travel about 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)
JAC

20. 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

21. Chain of Infection: Preventing Transmission
CDC recommended these isolation precautions in 1996:
Standard Precautions
Transmission-based Precautions
Airborne Precautions
Droplet Precautions
Contact Precautions

22. 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

23. 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

25. 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.

26. Respiratory Hygiene/Cough Etiquette

27. 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?

28. 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

29. 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 patient’s 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

30. 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

31. 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

32. 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)

33. Problematic Pathogens

34. Clostridium difficile a.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

35. 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

36. 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

37. 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

38. CDI: Healthcare Facility Infection Control
Contact Precautions for patients with known or suspected CDI
Soap & water hand hygiene; alcohol doesn’t 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

39. 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

40. 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

41. MRSA in the 21st Century

42. 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

43. 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

44. 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

45. 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

46. Carbapenem Resistance and Carbapenemase-Producing 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

47. Bad News
Antibiotic resistance is one of the world’s 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”)

48. CDC: 2011 Location of CRE Caused by KPC Enzyme; CRE Caused by Other Enzymes Noted

49. 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

50. 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.

51. FUNdamental Information: Knowledge 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 doesn’t kill spores

52. Is this a good thing or a bad thing?
SBF

53. Is this a good thing or a bad thing?
SBF

54. Is this a good thing or a bad thing?

55. Is this a good thing or a bad thing?

56. Is this a good thing or a bad thing?

57. Is this a good thing or a bad thing. (Don’t be alarmed
Is this a good thing or a bad thing? (Don’t be alarmed! This photo was staged – it’s not really blood!)

58. Is this a good thing or a bad thing?
JAC

59. Is this a good thing or a bad thing?
JAC

60. Concluding Comments