Bad News – Good News:
The Basics of Infection
Prevention and Control
July 2012
Judith Conway, RN, BS, CIC
Infection Control Coordinator
Communicable Disease Control Section
Office of Health Protection
Illinois Department of Public Health
E-mail: judith.conway@illinois.gov
Telephone: 217/557-3472
1
Session Overview
1.
2.
3.
4.
Fundamental information
“Germology terminology”
“Antibiotic resistance 101”
Chain of infection – routes of infectious disease
transmission
5. Brief review of basic infection prevention/control
recommendations used to prevent transmission
6. Problematic pathogens
7. Scenarios
2
Fundamental Information
• It’s a “bug-drug” war
– “Bug” = bacteria
– “Drug” = antibiotic
• Bad news: Some bacteria have become
increasingly resistant to antibiotics
• Good news: We can help prevent infectious
disease transmission by understanding and
applying basic infection prevention/control
practices
3
Antibiotic Resistant Germs
Antibiotic resistance can travel the globe
“Resistance anywhere is resistance
everywhere”
4
Welcome to Your New Normal…
5
FUNdamental Information:
Pre-Assessment
1) Antibiotics are drugs that fight infections caused by:
A) Bacteria
B) Viruses
C) Bacteria and viruses
2) FILL IN THE BLANKS: ____________ ___________ is the primary
strategy recommended by CDC as the foundation to prevent
transmission of infectious agents in all healthcare settings.
3) TRUE or FALSE? MRSA is spread by airborne transmission.
6
FUNdamental Information:
Pre-Assessment
4) Antibiotic-resistant pathogens are most frequently spread from
one patient to another in healthcare settings by:
A)
B)
C)
D)
Airborne spread resulting from patients coughing and sneezing
Patients coming in contact with contaminated equipment
The contaminated hands of healthcare workers
Substandard environmental maintenance
5) What is the IDPH recommendation for the length of time to
perform proper hand washing?
6) TRUE of FALSE? Clostridium difficile is readily killed by alcoholbased hand hygiene products.
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Is this a good thing or a bad thing?
“Germology Terminology”
Microorganisms
• Microorganisms: bacteria, viruses, fungi,
protozoa, helminths, rickettsia, prions
– Biologic agents capable of causing disease
– Also known as infectious agents or pathogens
– Commonly called “germs” or “bugs”
NOTE: In today’s session, we will focus exclusively on
bacteria
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“Germology Terminology”
Infection versus Colonization
• Infection: Bad news, bad news, bad news
– Bad news: You’ve got it (it = bacteria “X”)
– Bad news: It’s making you sick (invading your
tissues and cells)
– Bad news: It can be spread to others
• Colonization: Bad news, good news, bad news
– Bad news: You’ve got it (it = bacteria “X”)
– Good news: It’s not making you sick
– Bad news: It can be spread to others
10
Antibiotic Resistance 101
• What are antibiotics?
–Drugs used to fight infections caused
by bacteria
• It is important to remember that
antibiotics have no effect on viruses
• How do antibiotics work?
–2 main types of action
• Bacteriostatic: inhibit bacterial growth
• Bactericidal: kill bacteria
11
Antibiotic Resistance 101
• What is antibiotic resistance?
–Ability of bacteria to resist the effects
of an antibiotic
• How does it occur?
–Occurs when bacteria change in some
way that reduces or eliminates the
effectiveness of antibiotics
• Because the antibiotic isn’t effective, the
bacteria survive and continue to multiply
and cause harm
12
Antibiotic Resistance 101
• How do bacteria become resistant to
antibiotics?
–Bacteria have several mechanisms
• Some bacteria develop the ability to neutralize the
antibiotic
• Other bacteria rapidly pump out the antibiotic
• Still other bacteria change the antibiotic attack
site (on the bacterial cell wall) so that the
antibiotic can’t do its work of affecting bacterial
metabolism
• Additionally, some bacteria can transfer pieces of
DNA that code for resistance to other bacteria
13
Antibiotic Resistance 101
• What happens when bacteria
become resistant to antibiotics?
–Selective pressure: resistant bacteria
survive, multiply, and replace all the
sensitive (susceptible) bacteria that
were killed off
–Just like antibiotic-susceptible bacteria,
resistant bacteria can spread to other
people and cause colonization or
serious infections
14
Antibiotic Resistance 101
• Why are bacteria becoming resistant to
antibiotics?
– Antibiotic use promotes development of
antibiotic-resistant bacteria
• Every time a person takes antibiotics,
sensitive (susceptible) bacteria are killed,
but resistant bacteria may be left to grow
and multiply
– Overuse and misuse
• Antibiotics are not effective against viral
infections
15
Chain of Infection
Causative Agent
Mode of Transmission
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Chain of Infection:
Modes of Transmission
• Microorganisms are spread through
3 primary routes:
–AIRBORNE
–DROPLET
–CONTACT
• Direct contact
• Indirect contact
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Airborne Spread
• Least common mode of transmission
• Dissemination of airborne droplet nuclei (small-particle residue
[5 microns or smaller in size] of evaporated droplets that contain
the infectious pathogen and remain suspended in the air) or
dust particles containing the infectious pathogen
• Examples of diseases spread through airborne transmission:
–
–
–
–
–
–
–
–
Anthrax spores from contaminated environment
Chickenpox
Disseminated herpes zoster (shingles)
Measles (rubeola)
Novel Strain Influenza: airborne spread may occur, extent unknown
Severe Acute Respiratory Syndrome (SARS)
Smallpox
Tuberculosis
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Droplet Spread
• Pathogen is spread in large respiratory droplets that don’t stay
suspended in the air; they travel about 3 - 6 feet and then
drop to the ground/surfaces
• Studies have shown that the nasal mucosa and conjunctivae
(and, less frequently, the mouth) are susceptible portals of
entry for respiratory viruses
• Examples of diseases spread through droplet transmission:
– Influenza (seasonal influenza)
– Meningococcal Meningitis
– Mumps
– Pertussis (Whooping cough)
– Rubella (German measles)
– Severe Acute Respiratory Syndrome (SARS)
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Contact Spread
• Most common mode of transmission
• Direct contact: germs (microorganisms) are transferred directly
from one person to another person through physical contact
• Indirect contact: transferred from contact with a contaminated
item or contaminated hands
• Short list of examples of diseases spread through contact
transmission:
– Chickenpox
– C. diff
– Lice
– MRSA and other multidrug-resistant organisms (MDRO)
– Norovirus
– Scabies
– Smallpox
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Chain of Infection:
Preventing Transmission
CDC recommended these isolation
precautions in 1996:
• Standard Precautions
• Transmission-based Precautions
–Airborne Precautions
–Droplet Precautions
–Contact Precautions
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Standard Precautions
• Primary strategy recommended by CDC as the
foundation to prevent transmission of infectious
agents in all healthcare settings
• Basic level of infection prevention/control practices
to be used in the care of all patients at all times and
in all healthcare settings, regardless of suspected or
confirmed infection
– Intended to reduce the risk of transmission of bloodborne
and other pathogens from recognized and unrecognized
sources of infection
– Designed to both protect the healthcare worker and
prevent the healthcare worker from spreading infections
among patients
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Standard Precautions
• Five components of Standard Precautions:
1. Hand hygiene before and after touching a patient
2. Personal protective equipment (PPE) (gloves, gowns,
face protection [masks, goggles, face shields]) is used as
indicated to prevent exposure to blood, body fluids,
secretions, and excretions (except sweat), mucous
membranes, non-intact skin, or contaminated equipment
3. Safe injection practices (recommended in 2007)
•
One & Only campaign: ONE needle, ONE syringe, ONLY ONE time
4. Safe handling of potentially contaminated equipment or
surfaces in the patient environment
5. Respiratory hygiene/cough etiquette (recommended in 2007)
•
Cover Your Cough
23
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Alcohol-Based Hand Hygiene Products
“Alcohol-based products are more effective for
standard handwashing or hand antisepsis by
healthcare workers (HCW) than soap or
antimicrobial soaps… In studies examining
antibiotic-resistant organisms, alcohol-based
products reduced the number of multidrugresistant pathogens recovered from the hands
of HCWs more effectively than did hand
washing with soap and water.”
SOURCE: CDC Hand Hygiene Guideline, 2002; page 11.
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Respiratory Hygiene/Cough Etiquette
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Who, What, Where, When, & Why
• WHO: On whom is the Precaution(s) used?
• WHAT: What type of personal protective
equipment is used by healthcare worker(s)?
• WHERE: Where is the patient placed in the
hospital or LTCF?
• WHEN: When is the Precaution(s) used?
• WHY: Why is the Precaution(s) used?
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Standard Precautions
• WHO: All patients in all healthcare settings
• WHAT: Hand hygiene and PPE: healthcare workers
have clean hands and use of appropriate personal
protective equipment (gloves, gown, face protection)
as indicated by the nature of the interaction and the
extent of anticipated blood, body fluid etc. exposure
• WHERE: No special room placement is required
• WHEN: During all healthcare encounters
• WHY: Prevent transmission of bloodborne and other
pathogens from recognized and unrecognized
sources of infection
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Airborne Precautions
• WHO: Patient with known or suspected infection with
airborne infectious agent
• WHAT: Respirator and AIIR: healthcare workers will wear
respiratory protection (respirator) upon entry into
patient’s Airborne Infection Isolation Room (AIIR)
• WHERE: Airborne Infection Isolation Room (AIIR):
patient is placed in a room with special air handling and
ventilation capacity (negative air pressure)
• WHEN: During hospitalization or LTCF stay while patient
is known/suspected to be contagious
• WHY: Prevent transmission of airborne infectious agents
29
Droplet Precautions
• WHO: Patient with known or suspected infection with
droplet-spread infectious agent
• WHAT: Mask: healthcare workers will wear mask upon
room entry / when working within 6 feet of patient
• WHERE: Private room: patient is placed in a private
room, if available. Special air handling and ventilation
capacity are NOT required or indicated.
• WHEN: During hospitalization or LTCF stay while
patient is known/suspected to be contagious
• WHY: Prevent transmission of infectious agents spread
through close respiratory or mucous membrane
contact with infectious respiratory secretions
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Contact Precautions
• WHO: Patient with known or suspected infection with
contact-spread infectious agent
• WHAT: Gown and gloves: healthcare workers will wear
gown and gloves for all interactions that involve
contact with patient
• WHERE: Private room: patient is placed in a private
room, if available. Special air handling and ventilation
capacity are NOT required or indicated.
• WHEN: During hospitalization or LTCF stay while
patient is known/suspected to be contagious
• WHY: Prevent transmission of infectious agents spread
through direct or indirect contact
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How to Safely Don & Remove PPE
• The addddddition of a mask for certain spinal
procedures grew from recent evidence of an
associated risk for developing meningitis
caused by respiratroy flora
• The use of a mask when performing certain
high-risk, prolonged procedures involving
spinal canal punctures (e.g., myelography,
epidural anesthesia)
32
Problematic
Pathogens
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Clostridium difficile
a.k.a. C. diff
• Bacteria: spore-forming bacteria
• Toxin-producer: produces exotoxins (toxin A
and toxin B) that are pathogenic to humans
• Exotoxins: toxin A and toxin B
• Illness: diarrhea (known as Clostridium difficile
infection – CDI)
– Can also cause serious intestinal conditions, sepsis
– CDC estimates that 14,000 deaths occur annually
due to CDI
Main Symptoms of CDI
•
•
•
•
•
Watery diarrhea
Fever
Loss of appetite
Nausea
Abdominal pain/tenderness
Public Health definition of diarrhea: 3 or more loose stools
within a 24-hour period
Risk Factors for CDI
•
•
•
•
•
•
•
Antibiotic exposure
Proton pump inhibitors
Gastrointestinal surgery/manipulation
Long length of stay in healthcare settings
Serious underlying illness
Immunocompromising conditions
Advanced age
CDI: New Difficulties With an Old Pathogen
• Nationwide, increased rates of CDI, with more
severe disease and increased mortality
• Possible reasons include the emergence of a
new strain of C. diff with increase virulence
and/or antibiotic resistance
– New strain has increased production of toxins A
and B, and can produce an additional toxin known
as binary toxin
CDI: Healthcare Facility Infection Control
• Contact Precautions for patients with known or
suspected CDI
– Soap & water hand hygiene; alcohol doesn’t kill
spores
• Continue Contact Precautions until diarrhea ceases
and patient has been diarrhea-free for 3 days
• Ensure adequate cleaning and disinfection of
environmental surfaces, especially items likely to be
contaminated with feces
– During outbreaks, use a bleach-based disinfectant
or an EPA-registered disinfectant with a sporicidal
claim
Multidrug-Resistant Organisms
• Multidrug-resistant organisms (MDRO) are
microorganisms, predominantly bacteria,
that are resistant to 1 or more classes of
antibiotics
• In some cases, the microorganisms have
become so resistant that no available
antibiotics are effective against them
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Facts About MDRO Transmission
• Transmitted by the same routes as antibiotic
susceptible infectious agents
• Patient-to-patient MDRO transmission in
healthcare settings is usually via contaminated
hands of healthcare workers
• Contact Precautions are recommended to
prevent MDRO transmission in healthcare
settings
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MRSA in the 21st Century
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What is Staphylococcus aureus?
• Bacteria often referred to as “Staph”
• Carried on the skin or in the nose of
healthy people
– Approximately 30% of the population
carry it on the skin or in the nose
– Approximately 2% carry a type known as
MRSA
42
What Is MRSA?
• MRSA stands for Methicillin-Resistant
Staphylococcus aureus
• It is a type of Staph bacteria that is resistant to
certain antibiotics including penicillin,
methicillin, and amoxicillin
• HA-MRSA stands for healthcare-associated
MRSA
• CA-MRSA stands for community-associated
MRSA
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MRSA Infection
• In the community, most MRSA infections
are skin infections
• In healthcare settings, more severe or
potentially life-threatening infections may
occur among patients e.g., bloodstream
infection, pneumonia, surgical site
infection, urinary tract infection
• MRSA is spread by contact transmission
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ESBL-Producing Bacteria
• ESBL = Extended-Spectrum Beta-Lactamase
• Beta-lactams are a class of antibiotics
• Beta-lactamase is an enzyme that deactivates the
antibiotics
• ESBLs are enzymes that confer resistance to a broad
(extended) spectrum of beta-lactam antibiotics & third
and fourth generation cephalasporins
• ESBL-producing bacteria have been identified in E. coli,
and also in Klebsiella, Proteus, Pseudomonas,
Salmonella, and Serratia species
• ESBL-producing bacteria are spread through contact
transmission
45
Carbapenem Resistance and
Carbapenemase-Producing Bacteria
• Carbapenems: a class of beta-lactam antibiotics
(imipenem, meropenem, ertapenem, doripenem)
• Carbapenems have been used as a last line of defense
in treating infections caused by ESBL-producing
bacteria
• Some bacteria have developed the ability to produce
carbapenemase which is an enzyme that deactivates
carbapenem antibiotics
– KPC refers to Klebsiella pneumoniae
carbapenemase
– CRE refers to carbapenem-resistant
Enterobacteriaceae
• KPC / CRE are spread through contact transmission
46
Bad News
• Antibiotic resistance is one of the world’s most
pressing public health threats
• Antibiotic overuse increases the development of
drug-resistant germs
• It will be many years before new antibiotics are
available to treat some resistant infections
• Klebsiella pneumoniae carbapenemase (KPC)
infection -- a type of antibiotic resistant bacteria also
known as CRE -- is found in 37 states
• Resistance anywhere is resistance everywhere
– Antibiotic resistance can travel the globe
(Information source: CDC Web site “Get Smart for Healthcare”)
47
CDC: 2011 Location of CRE Caused by KPC Enzyme;
CRE Caused by Other Enzymes Noted
48
Good News
• Many healthcare facilities are making infection prevention a
patient safety priority
• Implementation and correct adherence to Standard
Precautions, and Contact Precautions when indicated, are
“low-tech” practices that help prevent MDRO transmission
• CDC has launched educational programs and campaigns to
promote the proper use of antimicrobial agents
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FUNdamental Information:
Knowledge Assessment
1) Antibiotics are drugs that fight infections caused by
A) Bacteria
B) Viruses
C) Bacteria and viruses
BACTERIA.
2) FILL IN THE BLANKS: ________ _________ is the primary
strategy recommended by CDC as the foundation to prevent
transmission of infectious agents in all healthcare settings.
Standard Precautions
1) TRUE or FALSE? MRSA is spread by airborne transmission.
FALSE: MRSA is spread by contact transmission.
50
FUNdamental Information:
Knowledge Assessment
4) Antibiotic-resistant pathogens are most frequently spread from
one patient to another in healthcare settings by
A) Airborne spread resulting from patients coughing and sneezing
B) Patients coming in contact with contaminated equipment
C) The contaminated hands of healthcare workers
D) Substandard environmental maintenance
The contaminated hands of healthcare workers
5) What is the IDPH recommendation for the length of time to
perform proper hand washing? 20 seconds of scrubbing
6) TRUE of FALSE? Clostridium difficile is readily killed by alcoholbased hand hygiene products. FALSE: alcohol doesn’t kill spores
51
Is this a good thing or a bad thing?
Is this a good thing or a bad thing?
Is this a good thing or a bad thing?
Is this a good thing or a bad thing?
Is this a good thing or a bad thing?
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Is this a good thing or a bad thing?
(Don’t be alarmed! This photo was staged – it’s not really blood!)
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Is this a good thing or a bad thing?
Is this a good thing or a bad thing?
Concluding Comments
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