APIC CHAPTER PRESENTATION 7/2014

Transcription

1 2014 CRE THE SUPER BUG - WHY ALL THE BUZZ? Susan Burns BS, MT, CIC, VA-BC Medical Science Liaison DISCLOSURE I am a paid employee of the clinical team of PDI Healthcare. The content of this presentation is not representative of the views of PDI or its ownership. There will be NO discussion of any PDI products and/or solutions in accordance with CE Requirements. Presentation will incorporate best practices from a variety of information sources that bridge medical disciplines. AFFILIATIONS Member of the Association for Infection Prevention and Epidemiology (APIC) Past-President, Education, & Nomination Board Member of the Great Lakes Chapter of the Association for Infection Prevention and Epidemiology (APIC-GL) Member and Industry Partner of the Association of Vascular Access Member of the Infusion Nurses Society and the Great Lakes Chapter (INS & INS-GL) Member of Society of Healthcare Epidemiology of America (SHEA) Past board member and current member of Michigan Society for Infection Prevention and Control (MSIPC)

2 OBJECTIVES Recognize the impact of antibiotic resistance in healthcare today Describe Enterobacteriaceae family of organisms and its resistance Explain the mechanism of action for antibiotic resistance Define the modes of transmission. Describe methods to prevent infection. HEALTHCARE-ASSOCIATED INFECTIONS (HAIS) 1 out of 20 hospitalized patients affected Associated with increased mortality Attributed costs: $26-33 billion annually HAIs occur in all types of facilities, including: Long-term care facilities Dialysis facilities Ambulatory surgical centers Hospitals CHANGING LANDSCAPE OF HEALTHCARE Growing populations at risk Immunocompromised individuals Low birth weight, premature neonates Transplant recipients on immunosuppressive therapy Special environments Intensive care and burn units Long-term care Ambulatory surgery, endoscopy, and infusion services

3 Healthcare has moved beyond hospitals Hospitals Dialysis Facilities Ambulatory Facilities Long-term Care CHANGING LANDSCAPE OF HEALTHCARE Organizational factors affect HAI prevention Administrative policies Antimicrobial utilization Staffing Education Organism adaptation to its environment Increased prevalence of antimicrobial-resistant pathogens WHY THE CONCERN? In the US, nearly 2 Million patients get an infection each year in a healthcare facility Of those patients, about 99,000 die as a result of their infection More than 70% of the bacteria that cause these infections are resistant to at least one of the drugs most commonly used to treat them Source: APIC Dispelling the Myths: The True Cost of Infections

4 MDRO S ARE EPIDEMIOLOGICALLY IMPORTANT PATHOGENS Options for treatment are limited MDRO s are associated with: Increased lengths of stay Increased costs Increased morbidity and mortality Can be transmitted in healthcare facilities Source: Centers for Disease Control and Prevention Guideline for Control of Multidrug-Resistant Organisms in Healthcare Settings, WHAT S THE BUZZ??? Superbugs Are Overpowering Antibiotics Even Faster Than the CDC Expected SUPER BUGS? MRSA (Methicillin Resistant Staph aureus ACINETOBACTER sp. CDIFF (Clostridium difficile) CRE Carbapenem-Resistant Enterobacteriaceae

5 WHY THE HYPE ON CRE? High mortality rate Easily spread by contact Transfer antibiotic resistance ESBL and CRE ESBL: Extended-Spectrum Beta Lactamase- Producing gram-negative bacteria CRE: Carbapenem Resistant Enterobacteriaceae Cause variety of infections: Pneumonia Bloodstream Infections Wound infections Resistant to many antibiotics and difficult to treat Source: APIC Text, Association for Professionals In Infection Control and Epidemiology, ESBL Gram negative organisms that produce an enzyme called beta-lactamase that causes resistance to these antibiotics: Penicillins Cephalosporins (1 st, 2 nd, 3 rd & 4 th generation) (Keflex, cefepine) Monobactams (Azactam) One or more Carbapenem Can usually be treated with one of the Carbapenems: Meropenem, Imipenem, Ertapenem, Doripenem Commonly isolated from: abscesses, blood, catheter tips, lungs, sputum, peritoneal fluid Risk Factors include: Recent surgery or instrumentation, admission to ICU, recent Abx therapy (esp. Beta lactams), prolonged hospital stay Source: APIC Text, Association for Professionals In Infection Control and Epidemiology, 2009.

6 CRE Gram negative organisms that produce one type of beta-lactamase enzyme called carbapenemase. Occurs typically in the Enterobacteriaceae family of bacteria Confers resistance to all currently available antibiotics, including Carbapenems Carbapenem Resistant Enterobacteriaceae Most common CRE is: Klebsiella pneumoniae - KPC Source: CDC MMWR, Vol. 58 No. 10 3/20/09 ANTIBIOTIC RESISTANCE MECHANISM OF ACTION ANTIBIOTIC GRAM-NEGATIVE RESISTANCE Antibiotic must enter the bacteria cell wall to kill the bacteria Resistant bacteria may: Produce a carbapenemase that neutralizes the antibiotic Develop a mechanism that pumps the antibiotic out of the cell through porin channels and prevents the antibiotic from destroying the bacteria TRANSFER OF RESISTANCE naid.nih.gov

7 History of antibiotic discovery and concomitant development of antibiotic resistance. Carbapenem resistance Davies J, and Davies D Microbiol. Mol. Biol. Rev. 2010;74: HOW DOES TRANSMISSION OCCUR? Patient Environmental Surfaces Patient Care Equipment Healthcare Worker SOURCES OF INFECTION Contaminated Hands Patient/Resident Healthcare Provider Patient s Family and Visitors Contaminated Environmental Surfaces Environmental Surfaces Light switches, Bed rails, Bedside tables, Patient gown and Bed linens Medical Equipment (stethoscopes, vital signs machines, portable equipment, phlebotomy trays) Contaminated Skin of the Patient

8 ADHERENCE TO INFECTION CONTROL GUIDELINES IS INCOMPLETE Transmission is preventable with current recommendations Failure to use proven interventions is unacceptable Only 30%-38% of U.S. hospitals are in full compliance Just 40% of healthcare personnel adhere to hand hygiene What about the other controls? Insufficient infection control infrastructure in non-acute care settings has allowed major lapses in safe care PREVENTION HOW DO WE PROTECT OURSELVES and OUR PATIENTS? METHODS OF PREVENTION Antibiotic Stewardship - Appropriate antibiotic and dosing Rapid Diagnosis of CRE (MDRO) Patient with history of CRE infection or colonization Contact Precautions Use of gloves & gowns by all persons entering the room, including visitors Handwashing Healthcare workers, visitors, and patients Skin Antisepsis - reduces colonized organisms on the skin Surface Disinfection High touch surfaces, shared medical equipment if applicable (should use dedicated equipment) Terminal Cleaning: Consider special cleaning procedures in contact precaution rooms

9 Hand Hygiene Wash hands with soap and water: If visibly soiled with blood or other body fluids Before eating After using the restroom For residents with C. difficile infection Use alcohol based hand sanitizer to decontaminate hands. Before direct patient contact After contact with patient s intact skin (i.e., vitals, repositioning) After contact with objects in the patient's environment After removing gloves Source: Hand Hygiene Core-Supplemental Slides, Centers for Disease Control and Prevention, SKIN ANTISEPSIS Helps reduce bacteria that potentially cause skin infection. For the preparation of the skin prior to surgery. For the preparation of the skin prior to injection. Testing Process: Measures immediate and persistent reduction after single treatment. TFM Endpoints Bacterial Reduction (log 10 ), 1-log CFU / pre-injection 2-log CFU / abdomen (dry site) 3-log CFU / groin (moist site) SKIN ANTISEPTICS Skin antiseptic properties Broad Spectrum Quick Persistence Maintain activity in the presence of organic matter Non-irritating Skin antiseptics Isopropyl Alcohol PVP/Iodine PCMX Chlorhexidine gluconate + IPA

10 DISINFECTION APPROACH TO MDRO S Stringent Hand Hygiene Routine Cleaning Daily and Terminal Disinfection Isolation Precautions PPE Prevention of MDRO s General EPA- Registered Disinfectant Pathogen Specific Approach DISINFECTION PRACTICE General cleaning Utilize hospital wide general disinfectant Consider broad-spectrum disinfectant for terminal cleaning Outbreak Consider product change if needed Consider disinfectant with CRE kill claim for contact precaution rooms and/or cohort unit(s) Endemic Consider product change in specialized units Limit to certain incoming patients (e.g., LTC, LTAC) ENVIRONMENTAL DISINFECTION Clean and disinfect surfaces and shared medical equipment that may be contaminated with pathogens Those that are in close proximity to the patient (e.g., bed rails, over bed tables, IV poles) Frequently-touched surfaces in the patient care environment (e.g., door knobs, surfaces in and surrounding toilets in patients rooms).

11 MECHANISM OF ACTION - DISINFECTANT SURFACE DISINFECTANTS Disinfectants typically have a positive charge Gram-negative bacteria typically have a negative charge Disinfectant is drawn to the bacteria Disinfectant Gram negative bacilli Disinfectant then Attacks and adsorbs through the cell wall disrupts the cell membrane which release potassium ions and other cell components Results in cell death Gram neg baci ative lli Block, Fifth Edition APPROPRIATE USE OF DISINFECTANT Concentration of the product (liquid dilution) Exposure time to disinfectant (contact time) Contact time stated by manufacturer based on testing performed for EPA on microbial load of bacteria (bioburden) Nature of object to be cleaned/disinfected Temperature and relative humidity Rutala, Wm. Disinfection and Sterilization Issues in Healthcare Facilities presented at SHEA pre-conference, March 18, Patient Safety Initiatives for MDROs Institute for Healthcare Improvement (IHI): 5 Million Lives Campaign The Joint Commission (TJC) National Patient Safety Goals Association for Professionals in Infection Control and Epidemiology (APIC) Target Zero: Guides to Eliminate MRSA, C. difficile and Acinetobacter baumannii CDC CRE Toolkit CRE prevention guide

12 CDC 2012 CRE TOOLKIT CORE MEASURES Hand Hygiene Contact Precautions Healthcare Personnel Education Use of Devices Patient and Staff Cohorting Laboratory Notification Antimicrobial Stewardship CRE Screening HAND HYGIENE Staff Proper technique Champions Monitor Feedback Patients Expect all healthcare workers to wash hands Clean own hands CONTACT PRECAUTIONS Colonized or infected Method to identify CRE history No recommendation to discontinue Ensure personnel are following proper protocol Hand hygiene Gloves & Gowns Dedicated or disinfected equipment Monitor adherence

13 HEALTHCARE PERSONNEL EDUCATION Education directed to all personnel Transmission of CRE How to prevent transmission Contact Precautions Hand Hygiene Dedicated equipment Disinfection of surfaces and multi-use equipment RECOMMENDATIONS CONT D DEVICE USE Minimize the use of devices Remove devices as soon as possible PATIENT AND STAFF COHORTING Single rooms Specified areas Dedicated staff LABORATORY IDENTIFICATION Provide rapid testing Notify immediately RECOMMENDATIONS CONT D ANTIMICROBIAL STEWARDSHIP Use antimicrobials appropriately Use a narrow spectrum antibiotic CRE SCREENING Pre-admission Previous admission ACTIVE SURVEILLANCE Provide rapid testing Notify immediately

14 ADDITIONAL SUPPORT Inter-facility communication Public Health Engagement Regional Prevention Strategies MONITORING AND COMPLIANCE Develop Policy and Procedures Develop Measures Observation of adherence to P& P New Infections Collect Data Analyze Data Present Findings Source: Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, Centers for Disease Control and Prevention, SUPER BUGS Survival of the fittest Realize they are here to stay In the environment In all healthcare facilities In or on ourselves Practice Prevention Methods

15 CULTURE CHANGE Many infections are inevitable; some might be preventable Each infection is potentially preventable, unless proven otherwise Consumers Public Health Medical Professionals Safe Healthcare is Everyone s Responsibility Patients Payors Government Healthcare Facilities REFERENCES Centers for Disease Control and Prevention. (2006). Guidelines for Control of Multidrug-Resistant Organisms in Healthcare Settings. CDC Guidelines for environmental infection control in healthcare facilities. MMWR 2003:52(RR 10): Million Lives Campaign (2008). Getting Started Kit: Sustainability and spread. Cambridge, MA: Institute for Healthcare Improvement. Institute for Healthcare Improvement 5 Million Lives Campaign. (2007). Murphy, D. & Whiting, J. (2007). Dispelling the myths: The true cost of healthcare-associated infections. Washington, DC: Association of Professionals in Infection Control and Epidemiology. Nafzinger, D. (2009). Environmental gram-negative bacilli. In R. Carrico (Ed). APIC Text. (Chapter 37). Washington, DC: APIC. WHO Save Lives; Clean Your Hands (2005). CDC Website CRE Organisms: CDC Vital Signs: Carbapenem-Resistant Enterbacteriaceae MMWR Mar 5, Guidance for Control of Carbapenem-resistant-Enterobacteriaceae (CRE) 2012 CRE Toolkit FC Tenover Mechanisms of Antimicrobial Resistance in Bacteria AJM(2006)Vol119(6A),S3 S10