1. Infection Prevention Stephanie Langdon, MSN, CIC
Infection Control Practitioner
Presbyterian Novant Health
Charlotte, NC

2. Medical asepsis vs. Surgical asepsis
Asepsis the freedom from disease causing microorganisms. Two types Medical and Surgical.
Medical asepsis practices intended to confine a specific organisms to a specific area. Can be clean or dirty.
Surgical asepsis or sterile technique practices intended to destroy all microorganisms

3. Types of Microorganisms Causing Infections
Bacteria (MRSA and VRE)
Viruses (Flu and Parvo)
Fungi (Aspergillus)
Parasites (Intestinal Worms)

4. Germs live everywhere!
Most microbes that live in our environment perform functions essential to our survival, a small percentage of them enter our bodies to cause an infection, and a smaller proportion cause a drug resistant infection.
Because microbes have extremely high replication rates, they can also mutate quickly to enable them to adapt to changing conditions.

5. Bacteria Most common infection causing microorganism
Lives on your skin and surfaces
Can live and be transported through air, water, food, soil, body tissues and fluids.

6. Staph Aureus to MRSA In the beginning Staph Aureus
Emergence of MRSA (1960’s)
Emergence of CA-MRSA (1990’s)

7. Terms You Might Hear Community Acquired MRSA (CA-MRSA)
Methicillin-Resistant Staph Aureus (MRSA)
Hospital Acquired MRSA (HA-MRSA)
Methicillin-Susceptible Staph Aureus (MSSA)
Colonized MRSA
Infected MRSA

8. CA-MRSA Control Measures
Also Try to Prevent
Know the difference between Cleaning and Disinfecting
First you clean then you disinfect
Use correct products
Skin
Surfaces 8

9. Disinfectants that Kill Germs on Skin
Alcohol based hand Sanitizers
Antibiotics Soaps and wipes made for skin
Good old soap and water (Doesn’t have to be antibiotic soap) 9

10. Disinfectants that Kill Bacteria on Surfaces
Sani-wipes (Kill time 10 minutes)
Virex (Kill time 3 minutes)
Dispatch (Kill time 1 minute)
Bleach kills everything (see handout)

11. Ultraviolet Waves
Ultraviolet waves are effective in killing bacteria and viruses. Hospitals use equipment that produce these waves to sterilize equipment, water and air in rooms. It is also used to treat acne and psoriasis. These are the same waves used in tanning beds.

12. CA-MRSA Control Measures
Cover all wounds
Train athletes in first aid for wounds and signs of infection
Encourage Good hygiene Practices
Discourage sharing of items
Establish routine cleaning schedules for shared equipment
Encourage players to report skin lesions

13. Investigational Findings
Increase number of Spider Bites reported in the Emergency Rooms cultures revealed MRSA.
CA-MRSA median Age is 23
HA-MRSA median Age is 68 (Naimi, T.S. et al. JAMA 2003, 290: )

14. Hospital vs. Community Acquired Infections
Hospital (Nosocomial) Acquired MRSA : defined by the CDC as MRSA acquired after 48 hours stay in the hospital with no previous documentation of a positive MRSA culture
Community Acquired MRSA: defined by the CDC as MRSA acquired in the community. If we test within 48 hours of admission and patient is positive this is a community acquired MRSA

15. How to Recognize an Inflammatory Response
1st Stage: Vascular and Cellular Responses
2nd Stage: Exudate Production
3rd Stage: Reparative Phase

16. Types of Infections
Colonized: defined as a carrier of the bacteria but you are not sick. Cultures (screening) are from nares or perirectal area.
Infected: defined as someone with a wound (infected area) that has been cultured and is positive for an infection

17. Off the Beaten Path VRE - Vancomycin Resistance Enterococus
C diff- Clostridium difficile or CTOX
ESBLs - extended-spectrum beta-lactamases (which are resistant to cephalosporin's and monobactam’s)

18. Chain of Infection (Six Links)
Etiologic Agent (Microorganism)
Reservoir
Portal of Exit from the Reservoir
Method of Transmission
Portal of Entry to the Susceptible Host
Susceptible Host

19. Isolation Types
Airborne
Droplet
Contact
Contact Enteric

20. Isolation Precautions
Airborne to prevent the transmission of highly contagious or virulent infections spread by small airborne droplets (smaller than 5 microns) examples know or suspected TB, chicken pox.
Droplet to prevent the transmission of diseases spread by large droplets (larger than 5 microns) Examples are meningococcal meningitis, pertussis, mumps

22. Airborne Precautions Disease requiring Airborne Precautions:
Mycobacterium Tuberculosis (MTB)
Measles
Other significant diseases (i.e. Pandemic Influenza)
For a complete list of diseases/conditions requiring Airborne Precautions see Appendix A 1 (Linked to CDC).
N 95 respirators or PARA are required for all employees upon entry to an Airborne Precautions room. We do this for Every Patient, Every Time!
Monitored Negative pressure is Required
During the pandemic influenza period we encouraged staff to use their N95 per shift but they had to wash their hands before they put the mask on and before they took their mask off. We also wanted them to use face protection. They could kept their mask in brown paper bags and discard at the end of the shift. Anyone that engaged in aerosol generating activities (e.g., collection of clinical specimens, endotracheal incubation, nebulizer treatment, bronchoscopy) should discard mask after each use.

23. Signs and Symptoms of TB
Night sweats
Coughing up blood
Weight loss
Why is a positive PPD not always a sign of TB.
What does the chest x-ray look like?
Are the sputum's that are collected every morning for three consecutive mornings positive for Acid Fast Bacilli?

24. TB Mycobacterium tuberculosis (MTB)
All other Mycobacterium’s can be called MOTT (mycobacterium other than tuberculosis)
Other Pulmonary Mycobacterium’s
Mycobacterium avium complex MAC , M. kansasii,
M. absessus, M. xenopi
Skin Mycobacterium’s
M. marinum
Wound infections
M. fortuitum, m. chelonea and m. absessus

25. Genus Species Genus Mycobacterium (ALL Fords) Species
M. Tuberculosis (Lincoln Continental)
M. Avium (Mustang)
M. kansasii (Taurus)
M. absessus (Fusion)
M. xenopi (Fiesta)
They ALL test positive for Acid Fast Bacilli

27. Special Airborne/Contact Precautions
This category is for diseases that can be transmitted to others through both the airborne and contact route.
Examples include:
Varicella Zoster Virus (VZV):
Chickenpox
and disseminated zoster/shingles
SARS-CoV
Disseminated means on more that one dermatone. An example of this would be if a patient has a rash on their stomach and on their face. Another example would be if a patient has a rash on both sides of their back. If in doubt call Infection Prevention.

28. Shingle Questions Who is considered immune?
Immunity comes from having the chicken pox or having the VZIG.
How do you know if the patient has zoster pneumonia? Positive sputum’s would be needed to verify the present of the herpes virus and CXR positive for pneumonia.
If the patient is positive for zoster pneumonia and has visible lesion on more than one dermatome is this considered disseminated zoster shingles or is it only localized? Consider disseminated zoster shingles.

30. Droplet Precautions Most frequent diseases we see:
Pertussis (Whooping Cough)
Neiserria Meningitis
Parvo (5th disease)
Flu
Our current practice for Flu patients is for staff to wear surgical mask. This may change pending further recommendations by the CDC. Everyone else must also don a surgical mask upon entry to room.

31. Bacterium Meningitis B for Bad
Neiserria meningitidis (Treat intimate exposures as well as patient)
Only treat Patient
Hemoplus influenzae
Streptococcus pneumonia
Streptococcus group B
L. monocytogenes

32. Isolation Precautions
Contact to prevent the transmission of potential diseases that are spread by close, direct, or indirect contact. Examples are MRSA, VRE and ESBL.
Contact Enteric same as contact but to remove bacteria have to wash hands with soap and water. Examples C diff.

34. How it is Spread
The primary method of MRSA transmission is by Contact, usually from people's hands.
The organism has been recovered from people's hands after they have touched contaminated material and before they have washed their hands.
The MRSA organism also is found among health care workers who carry the organism either in their nose or on their skin.
If a person carries MRSA in his or her nares, it can be transferred to patients by hand contact.

35. C. difficile: Do NOT Use Purell Hand Sanitizer
Use soap and water if you suspect the patient has C diff or is diagnose with C diff. If you only have waterless hand sanitizers you can use it until you can get somewhere that you can wash your hands with soap and water. Any one with diarrhea could have c diff. The rooms have to be cleaned with Clorox to kill the spores. Housekeeping managers gets a sheet daily of the rooms that positive c diff patients occupy. Yes they get a list of patients with c diff but if you take the signs down before your EVS staff has been informed this could lead to miscommunication. So please be thoughtful of others working with the patients.

36. When to use PPE (Personal Protective Equipment)
When it is warm
Wet
Not yours

37. Which is More Dangerous?
Hand Hygiene Initiative
Which is More Dangerous?
Great White Shark
(Carcharodon carcharias)
Which kills more lives??? Answer is MRSA
MRSA
(Methicillin Resistant Staphylococcus aureus)

38. We Know What To Do!