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Prevention of Nosocomial Infections

Manuel D. Rodriguez DO, MS, MPH, FACP

June 2017

mrodriguez@idsga.com

Disclosures

Member of the Speaker’s Bureau for AllerganDalvance and Teflaro

I intend to discuss off-label uses of drugs during this talk

Objectives

Define nosocomial infection

Review the four most common causes of nosocomial infectionsDiagnosis

Treatment

Prevention

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Objectives

Discuss other potential preventive strategies for nosocomial infectionsHand Hygiene

Isolation

Vaccines

Nosocomial Infections

The term "nosocomial" comes from two Greek words: "nosus" meaning "disease" + "komeion" meaning "to take care of."

“Nosocomial" should apply to any disease contracted by a patient while under medical care. Not those that are just “Hospital Acquired”

A nosocomial infection is specifically one that was not present or incubating prior to the patient's admission to the hospital.

Nosocomial Infections

Infections acquired in the hospital that are caused by viral, bacterial, or fungal pathogens

The most common causes include:

Blood stream infections (BSI)

Pneumonia (e.g. ventilator associated pneumonia [VAP])

Urinary tract infections (UTIs)

Clostridium difficile infection (CDI)

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Risk factors for developing a nosocomial infection

Duration of hospital stay

Indwelling catheters

Mechanical ventilation

Use of total parenteral nutrition (TPN)

Risk factors for developing a nosocomial infection

Antibiotic usage

Use of histamine (H2) receptor blockers (owing to relative bacterial overgrowth)

Age—more common in neonates, infants, and the elderly

Immune deficiency

Catheter-Related Bloodstream Infections

(CRBSI)

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CRBSI

In ICUs 15 million central vascular catheter (CVC) line days in the ICU per year are reported

CRBSI increase length of stay and cost

There are 80,000 CRBSIs in ICUs each year

Hospital wide a total of 250,000 cases of BSIs have been estimated to occur annually

CRBSI

Based on moderate evidence the use a midline catheter or peripherally inserted central catheter (PICC), instead of a short peripheral catheter, when the duration of IV therapy will likely exceed 6 days

Gauze or opaque dressings should not be used to cover the catheter insertion site

Remove the catheter if the patient develops signs of phlebitis (warmth, tenderness, erythema or palpable venous cord), infection, or a malfunctioning catheter

CRBSI

Obtain paired blood cultures from the CVC and peripheral stick when CRBSI is suspected prior to starting antibiotics

Cather tip culture previously recommended in the IDSA guidelines from 2009 is no longer recommended

CVC entry site exudate culture should be obtained if present

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CRBSI treatment

Duration of antimicrobial therapy for CRBSI depends on the clinical circumstances.

In uncomplicated CRBSI with negative blood cultures following catheter removal or guidewire exchange and institution of appropriate antibiotic therapy, the duration of therapy is usually 10 to 14 days; day 1 is the first day of which negative blood cultures

CRBSI Treatment

Four- Six weeks of therapy is recommended in patients with recent prosthetic valve placement or those with prosthetic valves, even if investigation fails to show evidence of endocarditis.

In the setting of persistent bacteremia >72 hours following catheter removal the recommended duration is at least four to six weeks.

CRBSI Treatment

Patients with complications related to bacteremia:Suppurative thrombophlebitisEndocarditisOsteomyelitisMetastatic infection

In general, the patient should receive antibiotic therapy for at least 7 to 10 days following device removal prior to the placement of a new CVC

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CRBSI Treatment

* Penicillin, if the strain is susceptible.¶ Pediatric experience is limited.Δ Additional alternative agents include linezolid, tedizolid, ceftaroline, telavancin, dalbavancin, and oritavancin.◊ Pending susceptibility results for the isolate.1.References: Fernandez-Hidalgo N, Almirante B, Gavalda J, et al. Ampicillin plus ceftriaxone is as effective as ampicillin plus gentamicin for treating Enterococcus faecalis infective endocarditis. Clin Infect Dis 2013; 56:1261.

CRBSI Treatment

TMP-SMX: trimethoprim-sulfamethoxazole; ESBL: extended-spectrum beta-lactamase.* Penicillin, if the strain is susceptible.¶ Pediatric experience is limited.Δ Additional alternative agents include linezolid, tedizolid, ceftaroline, telavancin, dalbavancin, and oritavancin.◊ Pending susceptibility results for the isolate.1.References: Fernandez-Hidalgo N, Almirante B, Gavalda J, et al. Ampicillin plus ceftriaxone is as effective as ampicillin plus gentamicin for treating Enterococcus faecalis infective endocarditis. Clin Infect Dis 2013; 56:1261.2.Farrell DJ, Flamm RK, Sader HS, et al. Antimicrobial activity of ceftolozane-tazobactam tested against Enteriobacteriaceae and Pseudomonas aeruginosa with various resistance patterns isolated in U.S. hospitals (2011-2012). Antimicrob Agents Chemother 2013; 57:6305.3.Zhanel GG, Lawson CD, Adam H, et al. Ceftazidime-avibactam: a novel cephalosporin/B-lactamase inhibitor combination. Drugs 2013; 2:159.

CRBSI Treatment

TMP-SMX: trimethoprim-sulfamethoxazole; ESBL: extended-spectrum beta-lactamase.* Penicillin, if the strain is susceptible.¶ Pediatric experience is limited.Δ Additional alternative agents include linezolid, tedizolid, ceftaroline, telavancin, dalbavancin, and oritavancin.◊ Pending susceptibility results for the isolate.1.References: Fernandez-Hidalgo N, Almirante B, Gavalda J, et al. Ampicillin plus ceftriaxone is as effective as ampicillin plus gentamicin for treating Enterococcus faecalis infective endocarditis. ClinInfect Dis 2013; 56:1261.2.Farrell DJ, Flamm RK, Sader HS, et al. Antimicrobial activity of ceftolozane-tazobactam tested against Enteriobacteriaceae and Pseudomonas aeruginosa with various resistance patterns isolated in U.S. hospitals (2011-2012). Antimicrob Agents Chemother 2013; 57:6305.3.Zhanel GG, Lawson CD, Adam H, et al. Ceftazidime-avibactam: a novel cephalosporin/B-lactamase inhibitor combination. Drugs 2013; 2:159.

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CRBSI General Guide

No need to replace a peripheral catheter any more than every 72-96 hours to reduce risk of infection and phlebitis in adults

Do not use fever alone as an indication to remove a CVC unless there is clinical suspicion

Guidewire exchange of a CVC can be performed if there is no sign of infection

CRBSI Prevention

Avoid the use of a femoral site for CVC

Subclavian site remains preferred over a jugular >>>> femoral In renal patients the subclavian site may need

to be avoided due to risk of stenosis

CRBSI Prevention

Ultrasound guidance should be used in placement of CVCs

Place a CVC with the minimum amount of ports needed

Remove the CVC as soon as possible

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Hospital Acquired and Ventilator Associated

Pneumonia (HAP/VAP)

HAP/VAP

Pneumonia that develops after more than 48 hours of hospitalization or mechanical ventilation.

Incidence of VAP ranges 10 to 25%

Estimated all-cause mortality of VAP is 25 to 50 %

HAP/VAP

Moving away from the term Healthcare Associated Pneumonia (HCAP); diagnosis made < 48 hours after admission with any of the following risk factors:1. Hospitalized in an acute care hospital for

> 48 hours 2. Resided in a nursing home or long-term care

facility;3. Received recent IV antibiotic therapy,

chemotherapy, or wound care within the 30 days preceding the current diagnosis;

4. Attended a hospital or hemodialysis clinic

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Date of download: 5/8/2017Copyright © 2000 American Medical Association. All

rights reserved.

From: Ventilator-Associated Pneumonia

Arch Intern Med. 2000;160(13):1926-1936. doi:10.1001/archinte.160.13.1926

Potential sources of bacteria causing ventilator-associated pneumonia. Bacteria residing in the oropharynx and gastrointestinal tract can contaminate the subglottic secretion pool, as demonstrated. Subglottic secretions above the endotracheal tube cuff are aspirated into the trachea and disseminated into the distal airways and lung parenchyma by the force of the ventilator (inset).

Figure Legend:

HAP/VAP

Subglottic suctioning endotracheal tubes was shown in a meta-analysis to have lower rated of VAP in patients who were intubated for more than 24 hours

Head of bed elevation has not been shown to definitively reduce the rates of VAP. Clinical guidelines recommend that the head of

the bed be elevated at least 30 degrees and patients not be left supine to prevent aspiration

HAP/VAP

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HAP/VAP

HAP/VAP

Ceftolozane/Tazobactam is in a phase 3 study to evaluate its efficacy in VAP. Currently it is being used off label for pneumonia at a higher dose of 3g IV Q8 hours instead of 1.5g IV Q8 hours

Ceftazidime/Avibactam just completed a study on HAP in February 2017. Results were presented at the 27th annual meeting of the European Congress of Clinical Microbiology and Infectious Disease

HAP/VAP Prevention

Use non-invasive positive pressure ventilation (NPPV) to prevent endotracheal intubation

Once intubated, encourage daily weaning trials and sedation holidays

Re-intubation is associated with a higher rate of VAP due to the increase risks of aspiration

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HAP/VAP Prevention

Antimicrobial-coated endotracheal tubes were shown in the North American Silver-Coated Endotracheal Tube (NASCENT) study to be associated with lower rates of VAP occurrence and microbiologically confirmed VAP when compared to conventional tubes

Theses tubes were not associated with decrease mortality, duration on vent, or length of stay in the ICU and were more costly ($90 vs $2)

HAP/VAP Prevention

Selective digestive tract decolonization (SDD) –Not recommended due to increase risk of the development of bacterial resistance

Oral decontamination using chlorohexidine has been shown in systemic reviews and meta-analysis to reduce the rate of VAPStrength of chlorohexidine affects outcomeEffect is most pronounced in cardiac surgery

patients

HAP/VAP Prevention

One of the largest hurdles if to have health care providers follow published guideline recommendations.Use of “bundles” in the ICU have not been well

studied, but generally recommendedEven when implemented studies have shown

that ICU physicians and nurses do not follow published recommendations for prevention of VAP; 37% and 22.3% respectively

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Catheter Associated Urinary Tract Infection (CA-UTI)

CA-UTI

The most common cause of health care-associated infection world wide

Rates of unnecessary urethral catheterization has been reported between 21% and 50% in studies

CA-UTI

Definition:The presence of symptoms or signs compatible

with UTI with no other identified source of infection in a patient who has an indwelling catheter in place

≥103 colony forming units (cfu)/mL of ≥1 bacterial species in a single catheter urine specimen or in a midstream voided urine specimen from a patient whose catheter has been removed within the previous 48 hrs

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CA-UTI

This differs from catheter associated asymptomatic bacteriuria (CA-ASB)

CA-ASB should not be screened for except in specific circumstances:Pregnancy

Research

CA-UTI

Signs and symptoms compatible with CA-UTI include new onset or worsening

Fever Flank pain

Rigors Costovertebral angle tenderness

Altered mental statusAcute hematuria

Malaise Pelvic discomfort

Lethargy with no other identified cause

CA-UTI

In those whose catheters have been removed, dysuria, urgent or frequent urination, or suprapubic pain or tenderness

In patients with spinal cord injury, increased spasticity, autonomic dysreflexia, or sense of unease are also compatible with possible CA-UTI

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CA-UTI

The presence of pyuria in an asymptomatic patient is not an indication for antimicrobial treatment regardless of the amount

Absence of pyuria in a patient with symptoms of CA-UTI should prompt for investigation of other causes

Odor or cloudiness of the urine alone should not be used to differentiate CA-ASB from CA-UTI or as an indication for urine culture or antimicrobial therapy

CA-UTI Diagnosis

A urine culture should be obtained prior to the start of antimicrobials in an individual suspected of having a CA-UTI

The specimen should be collected after a new catheter is in place

If the catheter is no longer needed a culture of a voided midstream urine specimen should be obtained

CA-UTI Treatment

Target empiric antimicrobial treatment based on local antibiograms

Duration of treatment is generally 7 days10-14 days of treatment can be considered in

patients who are slow to respond to initially

In women ≤ 65 y/o whose catheter has been removed and has no signs of pyelonephritis a 3 day course of antibiotics could be considered

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CA-UTI Funguria

Common finding in uncontrolled hospitalized diabetics, patients in the ICU, patients on prolonged courses of antibiotics who are asymptomatic should not be treated It is not a marker for systemic disease in

asymptomatic patients It is a marker for colonization

CA-UTI Funguria

Asymptomatic Funguria does not require treatmentExceptions:

NeutropeniaVery low birthweight infants (<1500 g)Urinary tract manipulation

Renal transplant is no longer considered an absolute indication to treat asymptomatic Candiduria

CA-UTI Funguria Treatment

Remove the catheter

For fluconazole sensitive Candida:200-400mg daily for 14 days

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CA-UTI Funguria Treatment

If fluconazole resistant:C. glabrata: amphotericin B deoxycholate 0.3

to 0.6 mg/kg IV daily with or without flucytosine 25 mg/kg orally four times daily for 1 to 7 days or flucytosine alone for two weeks

C. krusei: amphotericin B deoxycholate 0.3 to 0.6 mg/kg IV for 1 to 7 days

Amphotericin B deoxycholate bladder irrigation 50 mg/L sterile water daily for 5 days can be used for patients

CA-UTI Prevention

Possible reasons to use a cathetera) Urinary retentionb) Obstruction to the urinary tractc) Close monitoring of the urine output of

critically ill patientsd) Urinary incontinence that poses a risk to the

patient because of Stage 3 or greater ulcer to the sacral area

e) Comfort care for terminally ill patients

CA-UTI Prevention

There is insufficient evidence to recommend the use of antimicrobial coated catheters

Guidelines do not recommend the use of prophylactic antibiotics in patients with urinary catheters

Systemic

Bladder irrigation

Topical

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CA-UTI Prevention

Consider alternatives to the indwelling catheter such as intermittent catheterization

If a catheter is in place document why Assess the need for the inserted catheter

dailyRemove it as soon as possible

Case Presentation Holroyd KB, Rittenberg A, Pahwa A. Misanalysis of Urinalysis. A Teachable

Moment. JAMA Intern Med. 2016;176(4):432-433. doi:10.1001/jamainternmed.2016.0067

Case Presentation

64-year-old woman with history of a Bertolottisyndrome presented to an ER due to symptoms related to medication withdrawal.

She was concerned that her medication was habit forming and within 24 hours after stopping her tramadol and tizanidine developed a cough, myalgias, nausea, weakness and rhinorrhea; similar symptoms to when she had done this in the past.

ROS negative for GI symptoms such as abdominal pain or diarrhea.

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Case Presentation

Afebrile, blood pressure 150/70 mmHg, heart rate 115 bpm

ER performed a urinalysis although the patient had no evidence of urinary symptoms.

UA showed 4 epithelial cells per high-powered field (hpf), 10 WBC per hpf as well as large leukocyte esterase, negative nitrites and only rare bacteria.

Case Presentation

Prior to discharge the patient was prescribed a seven-day course of cefpodoxime 100 mg twice a day.

No urine culture was ordered

Case Presentation

4-5 days after ER discharge the patient developed watery diarrhea

The frequency increased to 10 per day with associated lower abdominal pain

She developed fever as high as 39.2°C and presented to the emergency department

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Case Presentation

Vitals at that presentation showed fever, BP 105/71 mmHg, HR 128 bpm, RR 20 bpm

Repeat urinalysis showed pyuria once again.

CBC showed elevated white count of 19.3 K/mm3

Case Presentation

The patient was admitted for sepsis and because of recent antibiotic use was started on oral vancomycin empirically

Stool PCR was positive for C. difficile toxin

Over the next 4 days the patient’s diarrhea decreased in frequency and her fever as well as elevated WBCs resolved

Case Presentation

She was eventually discharged to complete her course of oral vancomycin

In a recent study of a University Hospital and was found that 62% of patients admitted to the General medicine service had a urinalysis despite 85% of these patients not having any symptoms related to a urinary tract infection

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Clostridium difficile infection (CDI)

CDI

Clostridium difficile is a causative agent of antibiotic associated colitis

It is caused by a disruption in the normal fecal flora in a patient who have been previously exposed/colonized with C. diff

The route of transmission of C. diff is fecal-oral

Risk factors for acquiring C. diff include exposure to health care settings such as hospitals, nursing homes, other long-term care facilities, and dialysis centers

CDI

Risk factors

Antibiotic exposure: Highest Risk: fluoroquinolones > clindamycin

> broad spectrum cephalosporins > penicillins

Moderate risk: macrolides > trimethoprim-sulfamethoxazole

Rare: aminoglycosides > tetracyclines > metronidazole > vancomycin

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CDI

Risk factors

Age ≥ 65

Gastric acid suppression with either a proton pump inhibitor of H-2 blocker

CDI- Treatment

Stop inciting antibiotic(s)

Begin treatment if clinical suspicion high

Assess severity of disease

CDI- Treatment

Scoring system devised to identify patients with severe infection One point:

Age >60 yearsTemperature >38.3ºC, Serum albumin <2.5 g/dL (25 g/L)WBC >15,000 cells/microL

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CDI- Treatment

Scoring system devised to identify patients with severe infection

Two points:

Endoscopic evidence of pseudomembranous colitis OR

Treatment in the intensive care unit

CDI- Treatment

Mild to Moderate disease initial episode:

Metronidazole 500mg PO TID or 250mg PO QID for 10-14 daysAvoid use of oral vancomycin when possible

to avoid increased risk of developing vancomycin resistant enterococcus

CDI- Treatment

Mild to Moderate disease initial episode:

Vancomycin 125mg PO Q6 hours for 10-14 daysReserve for pregnant woman or those

allergic/intolerant to metronidazole

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CDI- Treatment

Second episode:Repeat same treatmentMost studies do not recommend further

treatment with metronidazole after a second course of due to it dose dependent risk of peripheral neuropathy

Consider fidaxomicin 200mg PO BID for 10 days

CDI- Treatment

Recurrent disease:Prolonged vancomycin taper:

125mg PO QID for 7-14 days125mg PO BID for 7 days125mg PO Daily for 7 days125mg PO Every Other Day for 7 days125mg PO Every Third Day for 14 days

CDI- Treatment

Recurrent disease:Vancomycin 125mg PO Q6 hours x 14 days

followed by rifaximin 400 mg three times for 20 days

Consider fecal transplant

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CDI- Treatment

Severe disease:Vancomycin 125mg PO Q6 hours

Higher doses of vancomycin (250mg, 500mg) Has not been shown to be of benefit given dose absorption kinetics or oral vancomycin in the colon

CDI- Treatment

Add IV antibiotics:Patients unable to tolerate PO or have signs

of ileus

Metronidazole 500mg IV Q8 hours

Tigecycline was used in a small case series of 4 refractory patients with some success

CDI- Treatment

Vancomycin enemaPatients with ileus and/or cannot tolerate

oral vancomycin

500 mg every 6 hours (in 100 mL 0.9% sodium chloride)

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CDI- Treatment

Surgery In patient with severe CDI surgical intervention

is advisable in the setting of peritoneal signs, severe ileus, or toxic megacolon.

Subtotal colectomy

Diverting loop ileostomy and colonic lavage

C. diff Treatment

Monoclonal antibodiesBezlotoxumab FDA approved in 2016 for

use in secondary prevention Patients at high risk for recurrent CDIAge ≥ 65

Bezlotoxumab binds to toxin BNot to be used in severe disease

C. diff Treatment

IV immunoglobulins (IVIG)Small case reports and limited data on

efficacy

Not currently recommended

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CDI - Prevention

Use antibiotics sparingly

Avoid gastric acid suppression

Follow contact isolation practices to prevent spread in hospitalized patients*

C. Diff Treatment

Hand wash with soap and waterAlcohol based scrubs used in the US cannot kill

C. diff spores

Patient’s at high risk of recurrent CDI Consider prophylactic vancomycin 125mg PO

BID vs QID

Hand Hygiene – how compliant are we?

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Hand Hygiene – The Lesson of Semmelweis

Ignaz Semmelweis was a physician in 1847 Vienna, Austria

He noticed that fever was more common on a maternity ward where medical students worked than it was on the ward where midwives provided care.

He believed that the students were contaminating their hands while dissecting cadavers and began telling them to was their hands in chlorinated lime after dissection and before examining patients.

Hand Hygiene – The Lesson of Semmelweis

The rate of infection fell sharply, as did the mortality rate.

12 women developed postpartum fever on a ward where the students had no contact with cadavers which prompted Semmelweis to infer that infection was also transmitted by living organisms

He began to ask that hand washing be performed between all patient examinations.

Hand Hygiene – The Lesson of Semmelweis

Few physicians believed Semmelweis’ theory and refused to publish his findings.

In 1851, and again in 1855, he was appointed to hospitals with high infection and mortality rates-and his hand antisepsis methods resulted in significant decreases in infection and mortality.

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Hand Hygiene

Globally health care workers are compliant with hand hygiene ~50%

There are lower rates of compliance with physicians when compared to nursing and allied health staff

In addition, there is variability in the type of institution and level of training as well as specialty

Hand hygiene – excuses?

I’m too busy

My skin gets too irritated

I wore gloves

I didn’t think of it

Patient care comes first

Hand Hygiene

Before and after any direct contact with patients

Immediately after removal of gloves

Before handling an invasive device not requiring a surgical procedure, including central intravascular catheters, urinary catheters or peripheral vascular catheters

After touching blood, body fluids, secretions, excretions, non-intact skin or contaminated items, even if gloves are worn

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Hand Hygiene

When moving from a contaminated to a clean body site on the same patient

After contact with inanimate objects in the immediate vicinity of the patient

After using the lavatory

Isolation

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Standard Precautions

Applies to all patientsHand hygiene

Use of Personal Protective Equipment (PPE)

Respiratory hygiene

Contact precautions

Infectious diarrhea

Multidrug resistant organisms (MDRO)

Viral conjunctivitis

Lice, scabies

Contact precautions

Adenovirus (contact + droplet)

Respiratory Syncytial Virus (RSV)

Severe Acute Respiratory Syndrome (SARS)

Zoster

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Droplet precautions

Use of Surgical maskAdenovirus (droplet + contact)

Influenza

Mumps

Rubella

Meningococcal

Airborne Precautions

Use of N95 mask

Measles

Tuberculosis (primary or laryngeal)

Varicella (airborne + contact)

Airborne Precautions

Use of N95 maskZoster (disseminated or immunocompromised

patient); (airborne + contact)

Middle Eastern Respiratory Syndrome Coronavirus (MERS-CoV)

SARS

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Vaccinations

Vaccines

Primary prevention is best

No vaccine is 100% effective

Herd immunity helps to increase overall vaccine effectiveness

Flu Vaccines

This year the following flu vaccines were recommended:Standard trivalent inactivated vaccine

High dose, including Quadrivalent

Recombinant Cell culture

Adjuvant

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Flu VaccineEarly-season 2016–17 flu vaccination coverage among

HCP was 68.5%, similar to early-season coverage during the 2015–16 season (66.7%).During the previous two seasons, flu vaccination coverage

increased by 12–13 percentage points from early season to the end of the season.

https://www.cdc.gov/flu/fluvaxview/hcp-ips-nov2016.htm

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Flu Vaccine

By occupation:

Highest among physicians (83.0%),

Nurse practitioners/physician assistants (82.8%),

Pharmacists (81.4%),

Nurses (80.7%),

Other clinical professionals (72.3%).

https://www.cdc.gov/flu/fluvaxview/hcp-ips-nov2016.htm

Flu Vaccine

Lowest:Administrative and nonclinical support staff

(65.3%) Assistants and aides (56.8%).

By work setting:Early season flu vaccination highest among HCP

working in hospitals (80.8%). Lowest among HCP working in long-term care (LTC)

settings (55.1%).

Flu Vaccine

The most common reason reported for not getting vaccinated:Fear of experiencing side effects or

Getting sick from the vaccine

The second most common reason was that they don’t think that flu vaccines work.

https://www.cdc.gov/flu/fluvaxview/hcp-ips-nov2016.htm

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Pneumococcal Vaccine

Effective in preventing invasive pneumococcal disease

Two current available vaccines:Pneumococcal conjugate vaccine (PCV13)

Pneumococcal polysaccharide vaccine (PPSV23)

Pneumococcal Vaccine

PCV13 originally only approved for children, but in 2011 was approved for adults 50 years or older by the FDA

Studies showed that PCV 13 was 75% effective in protecting vaccinated individuals against invasive pneumococcal disease 45% effective against pneumococcal pneumonia

The PPSV23 protects 50-85% of vaccinated individuals with healthy immune systems against invasive pneumococcal disease

Pneumococcal Vaccinations

Adults who are immunocompetent and aged 65 years or older should receive 13-valent pneumococcal conjugate vaccine (PCV13) followed by 23-valent pneumococcal polysaccharide vaccine (PPSV23) at least 1 year after PCV13.

Current recommendations are that adults receive 1 dose of PCV13 and 1, 2, or 3 doses of PPSV23 depending on indication.

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Pneumococcal Vaccinations

When both PCV13 and PPSV23 are indicated, PCV13 should be administered first; PCV13 and PPSV23 should not be administered during the same visit.

If PPSV23 has previously been administered, PCV13 should be administered at least 1 year after PPSV23.

When two or more doses of PPSV23 are indicated, the interval between PPSV23 doses should be at least 5 years.

Pneumococcal Vaccinations

No additional doses of PPSV23 are indicated for adults who received PPSV23 at age 65 years or older.

When indicated, PCV13 and PPSV23 should be administered to adults whose pneumococcal vaccination history is incomplete or unknown.

References

Andreas F. Widmer, Reno Frei, Stefan Erb, Anne Stranden, Ed J. Kuijper, CornelisW. Knetsch, Sarah Tschudin-Sutter; Transmissibility of Clostridium difficile Without Contact Isolation: Results From a Prospective Observational Study With 451 Patients. Clin Infect Dis 2017; 64 (4): 393-400. doi: 10.1093/cid/ciw758

Bonten MJ, Huijts SM, Bolkenbaas M, et al. Polysaccharide conjugate vaccine against pneumococcal pneumonia in adults. N Engl J Med. 2015;372(12):1114–25.

Gardam, M.A., Amihod, B., Orenstein, P., Consolacion, N., & Miller, M.A. (1998). Overutilization of indwelling urinary catheters and the development of nosocomial urinary tract infections. Clinical Performance & Quality Health Care, 6(3), 99–102.

Garey KW, Ghantoji SS, Shah DN, Habib M, Arora V, Jiang ZD, DuPont HL. A randomized, double-blind, placebo-controlled pilot study to assess the ability of rifaximin to prevent recurrent diarrhoea in patients with Clostridium difficile infection. J Antimicrob Chemother.2011 Dec;66(12):2850-5. doi: 10.1093/jac/dkr377. Epub 2011 Sep 21.

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References Herpers BL, Vlaminckx B, Burkhardt O, Blom H, Biemond-Moeniralam

HS, Hornef M, Welte T, Kuijper EJ. Intravenous tigecycline as adjunctive or alternative therapy for severe refractory Clostridium difficile infection. ClinInfect Dis. 2009 Jun 15;48(12):1732-5. doi: 10.1086/599224.

Holly Keyt, Paola Faverio, and Marcos I. Restrepo. Prevention of ventilator-associated pneumonia in the intensive care unit: A review of the clinically relevant recent advancements. Indian J Med Res. 2014 Jun; 139(6): 814–821. PMCID: PMC4164993

Holroyd KB, Rittenberg A, Pahwa A. Misanalysis of UrinalysisA Teachable Moment. JAMA Intern Med. 2016;176(4):432-433. doi:10.1001/jamainternmed.2016.0067

Jain, P., Parada, J.P., David, A., & Smith, L.G. (1995). Overuse of the indwelling urinary tract catheter in hospitalized medical patients. Archives of InternalMedicine, 155(13), 1425–1429.

References Kalil AC, Metersky ML, Klompas M, Muscedere J, Sweeney DA, Palmer

LB, Napolitano LM, O'Grady NP, Bartlett JG, Carratalà J, El Solh AA, Ewig S, Fey PD, File TM Jr, Restrepo MI, Roberts JA, Waterer GW, Cruse P, Knight SL, Brozek JL. Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis.2016 Sep 1;63(5):e61-e111. doi: 10.1093/cid/ciw353. Epub 2016 Jul 14.

Kollef MH, Afessa B, Anzueto A, Veremakis C, Kerr KM, Margolis BD, et al. Silver-coated endotracheal tubes and the incidence of ventilator-associated pneumonia: the NASCENT randomized trial. JAMA. 2008;300:805–13.

Manian FA. IDSA guidelines for the diagnosis and management of intravascular catheter-related bloodstream infection. Clin Infect Dis. 2009 Dec 1;49(11):1770-1; author reply 1771-2. doi: 10.1086/648113.

Moore MR, Link-Gelles R, Schaffner W, et al. Effectiveness of 13-valent pneumococcal conjugate vaccine for prevention of invasive pneumococcal disease in children in the USA: A matched case-control study. Lancet Respir Med. 2016 Mar 14. [ePub ahead of print]

References

Özçaka Ö, Başoğlu OK, Buduneli N, Tasbakan MS, Bacakoglu F, Kinane DF. Chlorhexidine decreases the risk of ventilator-associated pneumonia in intensive care unit patients: a randomized clinical trial. J Periodontal Res. 2012;47:584–92

Pappas PG, Kauffman CA Andes DR, Clancy CJ, Marr KA, Ostrosky-ZeichnerL, Reboli AC, Schuster MG, Vazquez JA, Walsh TJ, Zaoutis TE, Sobel JD. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2016 Feb 15;62(4):e1-50. doi: 10.1093/cid/civ933. Epub 2015 Dec 16.

Pilishvili T, Bennett NM. Pneumococcal disease prevention among adults: Strategies for the use of pneumococcal vaccines. Vaccine. 2015;33(4):D60–5.

Rello J, Lorente C, Bodi M, Diaz E, Ricart M, Kollef MH. Why do physicians not follow evidence-based guidelines for preventing ventilator-associated pneumonia? A survey based on the opinions of an international panel of intensivists. Chest. 2002;122:656–61

5/30/2017

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References

Ricart M, Lorente C, Diaz E, Kollef MH, Rello J. Nursing adherence with evidence-based guidelines for preventing ventilator-associated pneumonia. Crit Care Med. 2003;31:2693–96

Saint, S., Lipsky, B.A., & Goold, S.D. (2002). Indwelling urinary catheters: A one point restraint? Annals of InternalMedicine, 137(2), 125–127.

Saloojee H, Steenhoff A. The health professional's role in preventing nosocomial infections. Postgraduate Medical Journal 2001;77:16-19.

References Van Hise NW, Bryant AM, Hennessey EK, Crannage AJ, Khoury

JA, Manian FA. Efficacy of Oral Vancomycin in Preventing Recurrent Clostridium difficile Infection in Patients Treated With Systemic Antimicrobial Agents. Clin Infect Dis. 2016 Sep 1;63(5):651-3. doi: 10.1093/cid/ciw401. Epub 2016 Jun 17.

Yin P, Kiss A, Leis JA. Urinalysis Orders Among Patients Admitted to the General Medicine Service. JAMA Intern Med. 2015 Oct;175(10):1711-3. doi: 10.1001/jamainternmed.2015.4036.

Zar FA, Bakkanagari SR, Moorthi KM, Davis MB. A comparison of vancomycin and metronidazole for the treatment of Clostridium difficile-associated diarrhea, stratified by disease severity. Clin Infect Dis. 2007 Aug 1;45(3):302-7. Epub 2007 Jun 19.

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