INFECTION CONTROLBY MARY BETH VOGEL, BSN, RN-C

USELESS (USEFUL) FACTS!• ALCOHOL-BASED HAND RUBS TAKE LESS TIME TO

USE THAN H/W. IN AN 8HR SHIFT, AN ESTIMATED 1HR OF AN ICU NURSE'S TIME WILL BE SAVED BY USING AN ALCOHOL-BASED HANDRUB (CDC)

• THE CDC RECENTLY REPORTED THAT IN US HOSPITALS, HAI ACCOUNT FOR @ 1.7 MILLION INFECTIONS AND 99,000 ASSOCIATED DEATHS EACH YEAR. OF THESE INFECTIONS:

• 32 % OF ALL HAI INFECTIONS ARE UTI’S

• 22 % ARE SURGICAL SITE INFECTIONS

• 15 % ARE PNEUMONIAS/VAP

• 14 % ARE BLOODSTREAM INFECTIONS

THE BASICS

• MICROORGANISM/MICROBE/NON-PATHOGEN

• PATHOGEN

• NON-PATHOGENS

• NORMAL FLORA

• COLONIZATION

COLONIZED OR INFECTED:

WHAT’S THE DIFFERENCE?

• COLONIZATION: CARRY BACTERIA W/O EVIDENCE OF INFECTION

• INFECTION CAN OCCUR D/T COLONIZ

• HOW?

CLASSIFICATIONS OF MICROORGANISMS

1. BACTERIA• SINGLE CELLED MICROORG

• TX W/ ANTIBIOTICS

• RESISTANT BACTERIA ARE CAUSE OF HAI

• CATEGORIZATION:

• SIZE, SHAPE, CELLULAR ARRANGEMENT

• GROWTH REQ

• STAINING

Bacillus anthracis and WBC

A. COCCI

• ROUND

• DIPLOCOCCI

• STREPTOCOCCI

• STAPHYLOCOCCI

• EX:

• MRSA

• STREP THROAT

• PNEUMONIA

STREPTOCOCCI

STAPHYLOCOCCI

B. BACILLI

• ROD SHAPED

• SINGLE, PAIRED, CHAINS

• MAY CONTAIN FLAGELLA

• MAY FORM SPORES

• EX:

• TB

• TETANUS

• PERTUSSIS

• BOTULISM

• C-DIFF

TETANUS

C. SPIRILLA

• SPIRAL, COMMA OR CORKSCREW SHAPE

• EX:

• CHOLERA

• SYPHILIS

• LYME DISEASE

LYME DISEASE

D. SMALL BACTERIA

• ROUND/OVAL

• OBLIGATE INTRACELLULAR PARASITES

• EX:

• CHLAMYDIA

• ROCKY MOUNTAIN SPOTTED FEVER

• TYPHUS

E. NOSOCOMIAL INFECTIONS: HAI

• VRE: VANCOMYCIN RESISTANT ENTEROCOCCUS

• MRSA: METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS

• C-DIFF: CLOSTRIDIUM DIFFICILE

• EASILY SPREAD FROM PT TO PT; BY HOSP STAFF/EQUIPMENT

• REQUIRES PPE, ISOLATION

Recovery of VRE from Hands and Environmental Surfaces

Up to 41% of HCW’s hands sampled (after patient care and before hand hygiene) were positive for VRE

VRE were recovered from a number of environmental surfaces in patient rooms

VRE survived on a countertop for up to 7 days

The Inanimate Environment Can Facilitate Transmission

X represents VRE culture positive sites

2. PROTOZOA

• ONE CELLED MICROORG LGR THAN BAC

• EX: MALARIA

• TX: PREVENTION AND ANTIPROTOZOAN AGENTS

MALARIA

3. FUNGI

• SIMPLE PLANT LIKE MICROORG

• YEAST, MOLD

• FUNGAL/MYCOTIC INFECTIONS:

• RINGWORM, ATHLETES FOOT

• TOPICAL TX

RINGWORM

4. PRIONS

• “PROTEINACEOUS INFECTIOUS PARTICLE”

• MISFOLDED PROTEINS

• PATHOGENIC PROTEINS

• RARE

• BSE (BOVINE SPONGIFORM

ENCEPHALOPATHY)

• VCJD (VARIANT CREUTZFELT-

JAKOB DISEASE)

Spongiform change in CJD

Tonsil biopsy in CJD

5. PATHOGENIC ANIMALS

• ROUNDWORMS, TAPEWORMS

• MITES, TICKS, LICE, INSECTS, SPIDERS

6. VIRUS

• SMALLEST MICROORG; PARTICLE

• NUCLEIC ACID W/ PROTEIN COAT

• ENTERS HOST CELL, ALTERS DNA, REPLICATES

• SPREAD BY BODY FLUIDS

• DIFFICULT TO TX

• INCUBATION PD VARIES

• RHINOVIRUS, MUMPS, VARICELLA, INFLUENZA, HEPATITIS, HIV/AIDS, EPSTEIN-BARR, HPV, HERPES, MEASLES

HEPATITIS

• LIVER INFECTION

• TRANSMITTED BY BLOOD/BODY FLUIDS

• TYPES:

• HEPATITIS A: FOOD BORNE

• HBV: BLOODBOURNE

• HCV: BLOODBOURNE

• HEP D: OCCURS W/ B

• HEPATITIS E: UNCOMMON, SIMILAR TO A

• ETOH, AUTOIMMUNE, DRUG/TOXIN INDUCED

• ACUTE VS CHRONIC

HEPATITIS B

HEPATITIS C

INFECTION

• INVASION OF PATHOGENS CAUSES LOCAL CELLULAR INJ, SEC OF TOXINS OR ANTIGEN-ANTIBODY RXN IN HOST

• RISK: INADEQUATE DEF/IMMUN, INCREASED ENVIRONMENTAL EXP, MALNUTRITION, MEDS, TRAUMA

BODY DEFENSES• SKIN

• MUCOUS MEMB

• CILIA

• COUGHING/SNEEZING

• CHEMICAL INHIBITORS: TEARS, HCL

• NORMAL FLORA

• FEVER

• INFLAMMATION

• IMMUNE SYSTEM (WBC)

CATEGORIES OF INFECTIONS/DISEASES

• 1. ENDOGENOUS

• 2. EXOGENOUS

• 3. NOSOCOMIAL/HAI

• 4. OPPORTUNISTIC

• 5. ACUTE VS CHRONIC

• 6. SELF LIMITING

• 7. PRIMARY VS SECONDARY

• 8. LOCAL VS SYSTEMIC

CHAIN OF INFECTION

• CONDITIONS THAT ALLOW FOR SPREAD OF INFECTION

• 6 PARTS:

• 1. CAUSATIVE AGENT

• 2. RESERVOIR

• 3. PORTAL OF EXIT

• 4. MODE OF TRANSMISSION

• 5. PORTAL OF ENTRY

• 6. SUSCEPTIBLE HOST

ASEPSIS AND ASEPTIC TECHNIQUES

• ASEPSIS

• STERILE

• CONTAMINATED VS CLEAN

• ASEPTIC TECHNIQUES IN HC:

• HAND HYGIENE, PPE, CLEANING

EQUIP/ENV

• ULTRASONIC AND DISINFECTION

• STERILIZATION

• 2,000,000+ HAI OCCUR ANNUALLY IN THE US. HAI ADD @$5 BILLION IN EXTENDED CARE AND TX

• HAI OCCUR IN ABOUT 7-10% OF HOSPITALIZED PATIENTS AND ACCOUNT FOR @ 90,000+ DEATHS PER YEAR (CDC)

• MOST HCW RECOGNIZE THE IMPORTANCE OF H/W BUT ROUTINELY OVERESTIMATE THEIR OWN COMPLIANCE (CDC)

HAND HYGIENE

• ASEPTIC TECHNIQUE TO PREVENT HAI

• SKIN, NARES COLONIZATION CAN BE PATHOGENIC TO PTS

• PROTECTS PATIENTS, HCWS, VISITORS

• OBSERVATIONS IN PUBLIC RESTROOMS: ONLY 68% H/W BEFORE LEAVING

• WHEN SHOULD HCW WASH THEIR HANDS?

• ARRIVAL/DEPARTURE

• BEFORE/AFTER ALL PT CONTACT

• ANYTIME CONTAMINATION OCCURS

• BEFORE/AFTER GLOVES/PPE

• AFTER PICKING ANYTHING UP OFF FLOOR

• AFTER BATHROOM USE

• AFTER COUGHING, SNEEZING, BLOWING NOSE

• INBETWEEN PROCEDURES TO PREVENT CROSS CONTAMINATION

• AFTER HANDLING ANY SPECIMEN

• AFTER HANDLING ANY CONTAMINATED/SOILED ITEMS

• BEFORE/AFTER ANY CONTACT W/ MUCOUS MEMB

• BEFORE EATING

• AT LEAST 30 SECONDS!

EFFICACY OF HAND HYGIENE PREPARATIONS IN KILLING

BACTERIA

Good Better Best

Plain Soap Antimicrobial soap Alcohol-based handrub

1. Plain soap and water

2. Antimicrobial soap and water

3. Alcohol-based handrub

WHICH HAND HYGIENE METHOD IS BEST AT KILLING BACTERIA?

Which of the following hand hygiene agents is LEAST drying to your skin?

1. Plain soap and water

2. Antimicrobial soap and water

3. Alcohol-based handrub

Ability of Hand Hygiene Agents to Reduce Bacteria on Hands

Adapted from: Hosp Epidemiol Infect Control, 2nd Edition, 1999.

0.0

1.0

2.0

3.0 0 60 180 minutes

0.0

90.0

99.0

99.9log%

Ba

cte

rial R

edu

ctio

n

Alcohol-based handrub(70% Isopropanol)

Antimicrobial soap(4% Chlorhexidine)

Plain soap

Time After Disinfection

Baseline

• WATERLESS HANDRUB:

• INCREASES COMPLIANCE

• REDUCES A GREATER NUMBER OF BAC

• MUST APPLY TO ALL HAND SURFACES (CDC)

• HANDWASHING:

• SUDSY ACTION, ALKALI CONTENT OF SOAP, FRICTION REDUCE PATHOGENS

• USE WARM WATER, GOOD LATHER, POINT FINGERTIPS DOWN WHEN RINSING

• USE PAPER TOWEL TO TURN ON/OFF FAUCETS

TIME SPENT CLEANSING HANDS:

ONE NURSE PER 8 HOUR SHIFT

HAND WASHING WITH SOAP AND WATER: 56 MINUTES

• BASED ON SEVEN (60 SECOND) HANDWASHING EPISODES PER HOUR

ALCOHOL-BASED HANDRUB: 18 MINUTES

BASED ON SEVEN (20 SECOND) HANDRUB EPISODES PER HOUR

.

Alcohol-based handrubs reduce time needed for hand disinfection

Can a Fashion Statement Harm the Patient?

5

35

10

0

10

20

30

40

p<0.05

% R

eco

very

of

gra

m

neg

ativ

e b

acte

ria

Natural (n=31)

Artificial (n=27)

Polished (n=31)

ARTIFICIAL

POLISHEDNATURAL

Avoid wearing artificial nails, keep natural nails <1/4 inch if caring for high risk patients (ICU, OR)

STANDARD PRECAUTIONS

• CDC REGULATIONS

• ALL BODY FL/ALL PT ARE POTENTIAL SOURCES OF INF

• ALL HCW ALL THE TIME FOR ALL PT!!

• BREAKS THE CHAIN OF INF

STANDARD PRECAUTIONS GUIDELINES

• USE ANYTIME THERE IS POSS CONTACT W/: BODY FL

• RULES:

• H/W GUIDELINES

• PPE WHERE INDICATED

• NO JEWELRY

• DO NOT REUSE GLOVES

• MASKS MUST BE CHANGED Q 30 MIN OR IF WET

• SHARPS DISPOSAL, NO RECAPPING

• SPILL/SPLASH CLEAN-UP

• MOUTHPIECES FOR RESUSCITATION

• CONTAMINATED WASTE, LINEN HANDLING

• EXPOSURES MUST BE REPORTED!

TRANSMISSION BASED ISOLATION PRECAUTIONS

• FOR PT WITH COMMUNICABLE DISEASES

• USED IN ADDITION TO SP

• TYPE OF ISOLATION USED DEPENDS ON PATHOGEN INVOLVED, HOW IT IS SPREAD AND WHETHER IT IS ANTIBIOTIC RESISTANT

• SEVERAL TYPES:

1.CONTACT PRECAUTIONS

• MOST COMMON

• MICROORGANISMS SPREAD BY DIRECT/INDIRECT CONTACT (VRE, MRSA, C-DIFF)

• ALSO: GI,SKIN, EYE INF

• STANDARD PRECAUTIONS PLUS:

• GOWN, GLOVES. MASK IF IN NARES, SPUTUM

• LIMIT PT TRANSPORT

• DEDICATED PT CARE EQUIPMENT

• PINK SIGN AT TH (NO MC STUDENTS IF C-DIFF)

2. DROPLET PRECAUTIONS

• INF TRANSMITTED BY LG PARTICLE DROPLETS THAT ARE EXPELLED BY COUGHING, SNEEZING, TALKING

• MENINGITIS, PNEUMONIA, INFLUENZA, R/O MRSA

• STANDARD PRECAUTIONS PLUS:

• MASKS IF W/IN 3 FEET OF PT

• MASK PT DURING ANY TRANSPORT

• ORANGE SIGN

• NO MED CAREERS STUDENTS

3. AIRBORNE PRECAUTIONS

• PATHOGENS TRANSMITTED BY AIRBORNE DROPLET NUCLEI

• TB, CHICKEN POX, RUBELLA

• STANDARD PRECAUTIONS PLUS:

• SPECIALIZED AIR FILTRATION (NEG PRESS)

• FIT TESTED MASKS: N-95,P100 HEPA

• LIMIT PT TRANSPORT; PT MUST BE MASKED

• GREEN SIGN

• NO MED CAREERS STUDENTS!

4. PROTECTIVE/REVERSE ISOLATION

• FOR IMMUNOCOMPROMISED PATIENTS

• STANDARD PRECAUTIONS PLUS:

• PRIVATE ROOM

• FREQUENT DISINF OF ROOM, EQUIP

• PPE FOR ALL WHO ENTER

• SPECIALIZED AIR FILTRATION

• LIMIT PATIENT TRANSPORT

BLOOD BORNE PATHOGENS

• HBV, HCV, HIV

• REQUIRES ALL HC FACILITIES TO:

• HAVE A WRITTEN EXPOSURE PLAN

• TX EXPOSURES

• PROVIDE HEP B VACCINE

• PROVIDE PPE, H/W FACILITIES, DECONTAM PROCED, SHARPS DISPOSAL, EE TRAINING

• NO RECAPPING

• POST SIGNS FOR ANY POSS BIOHAZARDS

• @6-800,000 NEEDLESTICK INJ OCCUR ANNUALLY; HALF GO UNREPORTED

• POST INJ RISK OF TRANSMISSION: HIV .3%, HCV 1.8%, HBV 2-30% (CDC)

• TX: LABS, HBV IMMUNOGLOB AND REVACC, TETANUS, PROPHYLACTIC

ANTIVIRALS AND

ANTIBIOTICS

NEEDLESTICK SAFETY ACT

• UPDATE OF BBP STANDARD

• EMPLOYERS REQUIRED TO:

• USE SAFER DEVICES

• INCORPORATE TECHNOLOGY CHANGES

• SOLICIT INPUT FOR DIRECT PT CARE HCW

• MAINTAIN SHARPS INJURY LOG