Healthcare-Associated Infections and Infection Control Timothy H. Dellit, MD Medical Director, Infection Control Harborview Medical Center

Patient Safety and Infection Control Prevention, monitoring, and feedback Healthcare-associated infections Catheter-associated bloodstream infections Ventilator-associated pneumonia Surgical site infections Catheter-associated UTI Transmission of multidrug-resistant/marker organisms MRSA VRE Carbapenem-resistant Acinetobacter ESBL-producing organisms → MDR Enterobacteriaceae C. difficile Aspergillus in burn and immunocompromised populations Tuberculosis

Increasing Regulation and Reporting CMS RHQDAPU FY2013-FY2015 CLA-BSI SSI CA-UTI Central line bundle compliance MRSA bacteremia C. difficile Influenza vaccination of HCW CMS and “preventable events” FY2008 Catheter-associated urinary tract infection Vascular catheter-associated infections Mediastinitis after CABG FY2009 SSI following select orthopedic procedures Spinal fusion Elbow and shoulder arthroplasty SSI following bariatric surgery Mandatory reporting of healthcare-associated infections (HB 1106) Central line infections in ICU: July 2008 Ventilator-associated pneumonia: January 2009 Selected surgical site infections: January 2010 Cardiac surgery Total hip and knee arthroplasty Hysterectomy

“MDRO Bundle” Hand Hygiene Contact precautions Minimize shared equipment Environmental cleaning Healthcare-associated infections preventive bundles Catheter-associated BSI Ventilator-associated pneumonia Catheter-associated UTI SCIP measures Active surveillance cultures Chlorhexidine baths Antimicrobial stewardship Patient and staff education Lancet 2000;356:1307-12

Role of Environmental Contamination Contact Contamination Percent positive Percent of Surfaces Positive for MRSA Infect Control Hosp Epidemiol 1997;18:622-627

Who are you sleeping with? 40% increased risk of transmission associated with prior occupant’s MRSA or VRE carriage Arch Intern Med 2006;166:1945-1951 Infect Control Hosp Epidemiol 2011;32:201-6

To Survey or Not to Survey? Surveillance Cultures Reduce MRSA Bacteremia Interventions over 9 yr Sterile CVC placement Alcohol-based hand hygiene Hand hygiene campaign ICU surveillance for MRSA (16 months) 29% of newly detected MRSA carriers develop infection within 18 months 75% 67% Incidence density per 1000 pt-days 40% Reduced ICU transmission by 47% 43 vs. 23 cases per 1000 at risk patients Clin Infect Dis 2003;36:281-5 Clin Infect Dis 2006;43:971-8

VA MRSA Initiative Decreased transmission Reduced HAIs MRSA VAP MRSA CLA-BSI C. difficile in non-ICU VRE in ICU and non-ICU N Engl J Med 2011;364:1419-30

Active Surveillance and Contact Precautions in ICU Cluster randomized study in 18 ICUs Surveillance cultures for MRSA and VRE - Mean delay in results 5.2 days Control Intervention MRSA or VRE colonization or infeciton (rate per 1000 pt-days) 35.6 40.4 Days in Contact Precautions (%) 38% 51% Hand hygiene 59% 69% Gloves 72% 82% Gowns 77% N Engl J Med 2011;364:1407-18

Daily Chlorhexidine Baths Baseline CHG Baths P MRSA acquisition* 5.04 3.44 0.046 VRE acquisition* 4.35 2.19 0.008 VRE bacteremia* 2.13 0.59 0.0006 *per 1000 pt-days Crit Care Med 2009;37:1858-1865

Chlorhexidine baths in Trauma ICU Before and after introduction of daily CHG baths in TICU In pre-contact precaution era Reduction in CR-BSI from 8.4 to 2.1 per 1000 catheter-days (P=0.01) Reduction in MRSA VAP from 5.7 to 1.6 per 1000 vent-days (P=0.03) Arch Surg 2010;145:240-246

HMC Nosocomial MRSA Rates Quarterly Number of Cases 2007: 331 Cases 2008: 268 Cases 2009: 154 Cases 2010: 142 Cases 0.9 per 1000 pt-days Source: Infection Control, for more information, please contact Dr. Tim Dellit, thdellit@u.washington.edu Confidential QI

Which of the following bundle elements is NOT correct? VAP and head of bed > 30 degrees VAP and sedation awakening VAP and DVT prophylaxis Central line and maximum barriers including full body drape, sterile gown, sterile gloves, mask with eye protection, and haircover Central line and povidone-iodine skin prep Central line and hand hygiene

Central Line-Associated BSI ICU CVC utilization 0.39 – 0.71 catheters/pt 15 million catheter-days per year in US ICU rate 1.2 to 5.3 per 1000 catheter-days (NHSN mean) 80,000 CR-BSI annually in US ICUs Attributable mortality 0-35% Healthcare cost $296 million to $2.3 billion Attributable cost $15,000-$56,000 Prolonged ICU and hospital LOS Clin Infect Dis 2002;35:1281-307 National healthcare Safety Network (HNSN) Report, Data Summary for 2009

NHSN CLA-BSI Pathogens 1986-1989 1992-1999 2006-2007 Pathogen (%) (%) (%) Coag-negative staphylococci 27 37 34 Staphylococcus aureus 16 13 10* Enterococcus 8 13 16 Candida sp. 8 8 12 Enterobacter 5 5 4 Pseudomonas aeruginosa 4 4 3 Klebsiella pneumoniae 4 3 5 E. Coli 6 2 3 Clin Infect Dis 2002;35:1281-307 Infect Control Hosp Epidemiol 2008;29:996-1011 *MRSA 5.6%, MSSA 4.3%

Prevention of Catheter-Associated BSI IHI “Central Line Bundle” Hand hygiene Chlorhexidine skin prep Maximal barriers Full drape Mask, hair cover, sterile gown, sterile gloves Optimal catheter site selection Daily review of line necessity Implementation AND documentation Institute for Healthcare Improvement

Median Bloodstream Infections per 1000 Catheter-Days Bundle in Action Median Bloodstream Infections per 1000 Catheter-Days Months After Implementation Reduction in mean rate from 7.7 to 1.4 per 1000 catheter-days N Engl J Med 2006;355:2725-32

UHC Benchmark of Key Performance Measures Hospital Performance Patient Level % of cases median range Central Venous Catheter Placed in the Subclavian Vein 44.2% 14.3 – 73.3% Evidence of Maximal Barrier Precautions for Insertion 0.0% 0.0 – 8.2% Hand Washing 0.0 – 39.0% Full Body Drape 3.0% 0.0 – 46.3% Sterile Gloves and Gown 1.9% Cap and Mask 0.0 – 13.6% Chlorhexidine Skin Prep for Insertion 0.0 – 98.1% Daily Dressing Inspection 97.5% 25.1 – 100% Daily Assessment of Medical Necessity to Continue CVC 16.4% 0.0 – 100% Operational Yes % (n) Site # Best Practice* CVC Insertion Policy 11.8% (2) 29, 89 Mandated Use of a CVC Insertion Checklist 84, 87 UHC’s MVP Bundle of Care Interventions Infect Control Hosp Epidemiol 2008;29:440-2

National Reduction in CLA-BSI JAMA 2009;301:727-36

MRSA Central Line-Associate BSI 50% reduction in MRSA CLA-BSI (0.43 vs 0.21 per 1000 catheter-days) JAMA 2009;301:727-36

Hospital-Acquired UTI • 40% of healthcare-associated infections • 80% due to indwelling urethral catheter Survey of Hospital Monitoring Potential Strategies Insertion/care • Catheter reminders/ automatic stop orders • Bladder US scanners • Condom catheters • Antimicrobial catheters No monitoring (%) Clin Infect Dis 2008;46:243-50 Aymptomatic bacteriuria vs. Symptomatic UTI in patients without localizing GU symptoms

CA-UTI Pathogens NHSN 2006-2007 Infect Control Hosp Epidemiol 2008;29:996-1011

Catheter-Associated UTI Duration of catheterization is primary risk Providers unaware of catheter status Students 21% Interns 22% Residents 27% Attendings 38% Daily assessment of need, especially when transferred from ICU to floor Am J Med 2000;109:476-80

Ventilator-Associated Pneumonia Rate 0.7 – 7.4 per 1000 ventilator days (NHSN 2009) 10-30% of intubated patients Incidence increases with duration of MV Day 1-5: 3% risk per day Day 6-10: 2% risk per day > 10 days: 1% risk per day Attributable mortality rate 33-50% Increased LOS 7-9 days Cost of $40,000 per patient Accounts for 50% of ICU antimicrobials Clinical vs. microbiologic definitions Poor external quality measure Am J Respir Crit Care Med 2005;171:388-416

NHSN Pooled Mean VAP by Unit 2009 Report Rate per 1000 vent-days BICU: Burn PICU: Pediatric med/surg CICU: Coronary NICU: Neurosurgery CT ICU: Cardiothoracic SICU: Surgical MICU: Medical TICU: Trauma Am J Infect Control 2009;37:783-805

“Ventilator Bundle” Head of bed elevation > 30 degrees Daily “sedation awakening” and assessment of readiness to extubate Oral care (chlorhexidine) Peptic ulcer disease prophylaxis Deep vein thrombosis prophylaxis *Institute for Healthcare Improvement

Late Onset VAP Pathogens July 03 – June 04 (N=138) July 08 – June 09 (N=114) July 09 – June 10 (N=83) Acinetobacter 44 (32%) 4 (4%) ↓ 4 (5%) ↓ MRSA 32 (23%) 8 (7%) ↓ 2 (2%) ↓ MSSA 21 (15%) 30 (26%) 23 (28%) Haemophilus 20 (14%) 24 (21%) 13 (16%) Pseudomonas 13 (9%) 14 (12%) 15 (18%) Enterobacter 4 (3%) 12 (11%) 4 (5%) Klebsiella spp. 7 (5%) 7 (6%) 5 (6%) Serratia spp. 5 (3%) 1 (1%) E. coli 6 (4%) 6 (5%)

Which of the following has been demonstrated to reduce surgical site infections and is currently part of SCIP recommendations? Peri-operative prophylactic antibiotics should be given within 60 minutes after incision Peri-operative prophylactic antibiotics should be given within 60 minutes before incision and discontinued within 24 hours Peri-operative antibiotics should be continued until the drains are out Nasal carriage of S. aureus should be eradicated prior to surgery Pre-surgical bath with chlorhexidine

Surgical Care Improvement Project Implemented by CDC and Centers for Medicare and Medicaid Services in 2002 Nationally included procedures Cardiothoracic, vascular, colon, hip or knee arthroplasty, vaginal or abdominal hysterectomy Performance measures (Baseline of 34,133 medicare patients in 2001) Antimicrobial prophylaxis within 1 hr of incision (55.7%) Antimicrobial agent c/w current guidelines (92.6%) Discontinuation within 24 hours after surgery (40.7%) Also, clipping rather than shaving, normothermia, glucose control, morning beta-blocker, DVT prophylaxis Role of MRSA screening? Arch Surg 2005;140:174-82

Perioperative Prophylactic Antibiotics Timing of Administration 14/369 15/441 1/41 1/47 Infections (%) 1/81 2/180 5/699 5/1009 Hours From Incision N Engl J Med 1992;326:281-6

Society of Thoracic Surgeons Rationale Unique patient risks Cardiopulmonary bypass, systemic hypothermia Devastating sequelae of mediastinitis (7-20% mortality) No randomized studies < 48 hrs in CT surgery Major Recommendations Postoperative prophylactic antibiotics are given for 48 hours or less Duration not dependent on chest tube removal If risk for MRSA, then vancomycin AND cefazolin Routine mupirocin administration for all patients in the absence of documented negative testing for staphylococcal colonization Ann Thorac Surg 2006;81:397-404 Ann Thorac Surg 2006;83:1569-76

Is Vancomycin Alone Adequate? Pathogens causing deep SSI following CABG, Hip and Knee Arthroplasty Acceptable for cardiac, vascular, or orthopedic surgery: Beta-lactam allergy Documented rationale NNIS 1994-2003

Meta-analysis of Seven Randomized Studies: Glycopeptide vs Meta-analysis of Seven Randomized Studies: Glycopeptide vs. β-Lactam for Prevention of Surgical Site Infection after Cardiac Surgery MSSA more frequent in vancomycin group 3.7% vs. 1.3% (J Thorac Cardiovasc Surg 2002;123:326-32) Clin Infect Dis 2004;38:1357-63

Intranasal Mupirocin and Surgical Site Infections Nasal carriage of S. aureus and risk of surgical site infection Orthopedic surgery with prosthetic implants in 272 patients, RR 8.9 (Infect Control Hosp Epidemiol 2000;21:319-323) Cardiothoracic surgery in 1980 patients, OR 9.6 (J Infect Dis 1995;171:216-9) 10/10 pre- and post-surgical pairs identical by phage typing Randomized, double-blind, placebo-controlled trial of pre-surgical mupirocin in 3864 patients (N Eng J Med 2002;346:1871-7) No difference in nosocomial infections, nosocomial S. aureus infections, or S. aureus surgical site infections S. aureus carriers (N=891) 4.5 fold increase in S. aureus SSI Significant reduction in S. aureus nosocomial infections (4.0 vs. 7.7) Trend towards decreased S. aureus SSI (3.7 vs. 5.9, 37%, P=0.15) Same strain in nares and site of infection in 85%

Universal Screening of Surgical Patients? JAMA 2008;299:1149-57 Prospective, cross-over study of 21,754 surgical patients 87% on admission MRSA colonization 5.1% Standard practices for all patients with MRSA Contact precautions Adjustment of pre-op prophylaxis Intranasal mupirocin and chlorhexidine body wash No difference in MRSA SSI (0.99 vs. 1.14 per 100) 34% of MRSA carriers did not receive appropriate pre-op prophylaxis None identified through outpatient screening developed MRSA infection

2% Chlorhexidine and 70% alcohol (Chloraprep) vs 2% Chlorhexidine and 70% alcohol (Chloraprep) vs. 10% Povidone Iodine for Surgical-Site Antisepsis Randomized, multi-center 849 patients Clean-contaminated surgery NNT: 17 patients N Engl J Med 2010;362:18-26

Pre-operative Chlorhexidine Baths Cochrane Review of six randomized trials with 10,007 patients RR Chlorhexidine vs. placebo 0.91 (0.80 to 1.04) Chlorhexidine vs. bar soap 1.02 (0.57 to 1.84) Chlorhexidine vs. no washing 0.36 (0.17 to 0.79) Cochrane Database Syst Rev. 2007 Apr 18;(2):CD004985. Review

It’s a small world… 26 y o medical student returns April 20, 2009 from an international elective in Mexico. On April 27 she presents to ED with 4 day h/o fever 39 C, cough, HA, myalgias, and diarrhea. That same day you hear reports of a novel Influenza A virus H1N1 associated with increased mortality in Mexico.

Which of the following is MOST correct regarding influenza? No special precautions are necessary for patients with suspected influenza since it is not very transmissible. Influenza is primarily transmitted by large droplets (> 5 microns), therefore healthcare workers should use Droplet Precautions with a surgical mask with eye protection for routine care to prevent contamination of mouth, nose, and conjunctiva. Patients with 2009 H1N1 should be placed in airborne isolation with use of N-95 respirators while patients with H1N1 seasonal influenza should be placed in droplet precautions. A negative rapid antigen test rules out influenza Influenza vaccination of healthcare workers does not have an impact on patients.

Modes of Transmission Droplets Airborne Contact Thought to be primary mode of transmission Coughing, sneezing, and talking Heavy; settle within 6 feet of the source Airborne Related to procedures → aerosolized particles Contact Direct: skin-to-skin contact Indirect: contact with virus in the environment 43

Respiratory Protection Debate CDC (during 2009-2010 influenza season) Fit-tested N95 respirators for care of patients with 2009 H1N1 Prioritized usage if limited resources Yet, Standard and Droplet Precautions for seasonal influenza? Infection Control and Infectious Diseases Societies* No evidence that 2009 H1N1 transmitted differently than seasonal influenza Standard and Droplet Precautions for routine care *Recommending organizations: World Health Organization (WHO) • Infectious Disease Society of America Healthcare Infection Control Practices • Society for Healthcare Epidemiology of America Advisory Committee (HICPAC) • Association of Professionals in Infection Control

Surgical Mask vs. N95 Respirator Randomized Study Characteristic Surgical Mask N=212 N95 Respirator N=210 P Vaccinated 68 (30.2%) 62 (28.1%) Lab-confirmed* RT-PCR H1N1 serology Serology without symptoms 50 (23.6%) 6 (2.8%) 17 (8.0%) 29/44 (65.9%) 48 (22.9%) 4 (1.8%) 25 (11.9%) 31/44 (70.5%) 0.86 0.75 0.18 Physician visits 13 (6.1%) 13 (6.2%) 0.98 Influenza-like illness, Fever and cough 9 (4.2%) 2 (1.0) 0.06 Work-related absenteeism 42 (19.8%) 39 (18.6) *RT-PCR or serology JAMA 2009;302:1865-71

UW Medicine Standard, Droplet, and Contact Precautions for routine care Place mask on coughing patients Separate sick from non-sick patients Surgical mask, eye protection, gown, and gloves N95 respirators for higher-risk aerosol-generating procedures Intubation and extubation Bronchoscopy Open suctioning of airway Cardiopulmonary resuscitation Suspected or Confirmed Cases of Influenza

43 y o woman from Eritrea with 3 week h/o non-productive cough, fever, and night sweats

Now What? AFB smear neg x 5 (3 sputum, 2 BAL) Sputum AMTD neg

Which of the following is the BEST approach? Remove from airborne isolation as a negative AMTD test rules out infectious TB Begin 4 drug therapy and remove patient from airborne isolation due to multiple negative AFB smears Begin 4 drug therapy and keep in airborne isolation Obtain interferon-gamma releasing assay (IGRA) as a negative result would rule out TB

44 y o Vietnamese man with 6 month h/o pain and swelling of left medial thigh associated with fevers and night sweats

Pulmonary Involvement in Extrapulmonary TB • 72 patients with XPTB 36 lymph nodes 12 pleura 6 CNS 6 GI • 57 had sputum collection • Weight loss associated with positive sputum cx OR 4.3 (1.01-18.72) 49% had abnormal CXR Chest 2008;134:589-94

Sputum AFB Smear Smear positive Smear negative, culture-positive TB 5,000-10,000 organisms per ml of sputum must be present Smear negative, culture-positive TB Responsible for roughly 17% of TB transmission in San Francisco and Vancouver 40-50% of pulmonary TB cases in King County are smear negative Am Rev Respir Dis 1966;95:998 Lancet 1999;353;444, Thorax 2004;59:286

Patient Safety and Infection Control UW Medicine Strategic Goals Reduction in HAI Expectation of hand hygiene with EVERY patient EVERY the time WSHA elimination of HAI by 2012 Mandatory reporting of HAI CLA-BSI, VAP, selected surgical site infections MRSA legislation Increased linkage of reimbursement to quality CMS preventable “medical errors”