Infection Prevention & Control of Multidrug-resistant Organisms in Ambulatory Surgical Centers

1. Infection Prevention & Control of Multidrug-resistant Organismsin Ambulatory Surgical Centers Jane Harper, RN, MS, CIC Lindsey Lesher, MPH Minnesota Department of Health Acute Disease Investigation and Control Section

2. Objectives • Describe multidrug-resistant organisms (MDRO) • Describe MDRO surveillance trends in Minnesota • Describe MDRO infection prevention and control measures in ambulatory surgical centers • Describe antibiotic resistance

3. Drug-resistant 'superbugs' hit 35 states, spread worldwide By Steve Sternberg, USA TODAY Sept. 17, 2010 Bacteria that are able to survive every modern antibiotic are cropping up in many U.S. hospitals and are spreading outside the USA, public health officials say. The bugs, reported by hospitals in more than 35 states, typically strike the critically ill and are fatal in 30% to 60% of cases. Israeli doctors are battling an outbreak in Tel Aviv that has been traced to a patient from northern New Jersey, says Neil Fishman, director of infection control and epidemiology at the University of Pennsylvania and president of the Society of Healthcare Epidemiologists. The bacteria are equipped with a gene that enables them to produce an enzyme that disables antibiotics. The enzyme is called Klebsiella pneumoniae carbapenamase, or KPC. It disables carbapenam antibiotics, last-ditch treatments for infections that don't respond to other drugs.

4. Multi-drug Resistant Organisms (MDRO) • Bacteria that acquire the ability to resist treatment against more than one antibiotic • Infections caused by MDRO: • More difficult to treat; require more toxic antibiotics • Often result in poor patient outcomes • Cost more • MDRO are readily transmitted in healthcare settings

5. SSI: surgical site infection CLABSI: central line-associated bloodstream infection VAP: ventilator-associated pneumonia CAUTI: catheter-associated urinary tract infection Source: CDC

6. Staphylococcus aureus • ~ 20% of humans are persistently colonized (children > adults); ~ 60% are intermittently colonized • Most often spread via contaminated hands

7. Methicillin-Resistant S. aureus (MRSA) • Resistant to beta-lactam antibiotics (all penicillins and cephalosporins) • Identified based on antimicrobial susceptibility testing

8. MRSAClinical Spectrum Severe / Invasive Infections Skin Infections Colonization

9. “Types” of MRSA • Community–associated (CA-MRSA) • Skin infections common • No recent hospitalization, dialysis, surgery, LTCF residence • Susceptible to most antibiotics except beta-lactams and erythromycin • Healthcare-associated (HA-MRSA) • Causes nosocomial pneumonia, surgical wound, and bloodstream infections • Risk factors: hospitalization, LTCF resident, dialysis, surgery • Resistant to many antimicrobials

10. MRSA Cases Reported to MDH, 2000-2009 56% CAMRSA 12% CAMRSA Total No. of Cases 56% 51% 53% 41% 34% 22% 18% 14% 12% 12% Year

11. Carbapenem-Resistant Enterobacteriaceae (CRE)

12. Carbapenems • Class of antibiotics • Mainstay of treatment targeting resistant Gram-negative bacilli • Ertapenem, imipenem, meropenem, doripenem

13. Enterobacteriaceae • Large family of Gram-negative bacteria • Common species • Klebsiella pneumoniae • Escherichia coli • Enterobacter cloacae • Enterobacter aerogenes

14. Carbapenem-Resistant Enterobacteriaceae(CRE) • Resistant to ≥3 classes of antibiotics, including carbapenems • Resistance mechanisms • Enzymes that inactivate carbapenems • Klebsiellapneumoniaecarbapenemase (KPC) • New Delhi Metalloβ-lactamase (NDM-1) • Located on chromosomes or plasmids (mobile genetic elements)

15. CRE Cases Reported to MDH, 2011

16. What kinds of infections do CREs cause? • Urinary tract, intestinal or abdominal, respiratory tract, and wound infections • Most frequently isolated from urine, sputum, or blood • Bloodstream infections are associated with higher rates of death than infection at other sites Patel JB. Presented at 107th ASM General Meeting, 2007 Agmon O. Presented at 8th Congress of IFIC. 2007

17. Who is at increased risk for infection with CREs? • Hospitalized patients with: • Co-morbid conditions • Frequent or prolonged hospitalization • Invasive devices • Antimicrobial exposure (vancomycin, fluoroquinolones, penicillins, and extended-spectrum cephalosporins) Esther T. Tan, et al. CID. Submitted

18. Clostridium difficile (C. diff)

19. C. difficile Bacteria • Named due to difficulty to isolate in the lab (Latin difficile = difficult) • Spore-forming, anaerobic, gram-positive bacillus • Fecal-oral transmission • Hands of healthcare personnel • Contaminated inanimate objects • Two major reservoirs: • Infected humans (symptomatic or colonized) • Inanimate objects CDC Fact Sheet, 2005 Simor ICHE, 2002

20. C. difficile Infection(CDI) Facts Hospital stays from C. difficile infections tripled in the last decade, posing a patient safety threat especially harmful to older Americans. Almost all C. difficile infections are connected to getting medical care. Hospitals following infection control recommendations lowered C. difficile infection rates by 20% in less than 2 years. CDC. http://www.cdc.gov/vitalsigns/hai/

21. Risk Factors for C. difficile Infection Antimicrobial exposure Acquisition of C. difficile Advanced age Underlying illness Immunosuppression Tube feeds Gastric acid suppression Use of nasogastric or gastrostomy feeding tubes Use of proton-pump inhibitors Main modifiable risk factors

22. CDI and Antibiotic Use • > 90% cases occur during or after antibiotic therapy • All antibiotics implicated; • Broad spectrum agents are more likely associated

23. Fever • Cramping abdominal pain • Increased frequency of loose, watery, unformed bowel movements not due to another cause • Recent history of antibiotic exposure Clinical Manifestations of CDI Asymptomatic colonization Diarrheal illness Pseudomembranous colitis Toxic megacolon • Asymptomatic colonization may be protective against CDI SHEA and IDSA Guidelines, 2007

24. BI/NAP/027 Increased Toxin Production Severe Clinical Disease Fluoroquinolone Resistance New Epidemic Strain of C. difficile Severity of Clostridium difficile infection is increasing

25. MDH CDI Surveillance • Population- & laboratory-based surveillance • Four central MN counties: Benton, Stearns, Morrison, Todd • Olmsted county MDH CDI Surveillance, 2011

26. Summary of MDRO Surveillance • Infections caused by MDRO are increasing • MDRO infections require more toxic, expensive antibiotics and result in increased adverse drug reactions • MDRO threaten the effectiveness of existing antimicrobials • MDRO are transmissible in healthcare settings and the community

28. Ambulatory Surgical Centers • Increasing and more complex, invasive care provided in ambulatory care facilities • Procedures performed in ASC: • 1996: 32 million • 2006: > 53 million • From 1996 to 2006: • 273% increase in spinal cord injections (increase of 1.5 million) • 200% more colonoscopies (increase of 4 million) Data from the National Survey of Ambulatory Surgery GAO. HHS Has Taken Steps to Address Unsafe Injection Practices, but More Action Is Needed. 2012.

29. Increased Awareness of Infection Prevention & Control Needs in ASCs Government Accountability Office (GAO) Report (2009) “The increasing volume of procedures and evidence of infection control lapses in ASCs create a compelling need for current and nationally representative data on HAIs in ASCs in order to reduce their risk…”

30. Infection Prevention & Control Strategies • Standard Precautions • Isolation Precautions • Hand hygiene • Injection safety • Cleaning and high-level disinfection/sterilization of reusable medical equipment

31. Standard Precautions • Basic level of infection control precautions for use in the care of all patients • Applies to: • Blood and all body fluids, secretions and excretions • Non-intact skin • Mucous membranes • Personal protective equipment as indicated by patient/procedure/situation • Hand hygiene - always! • Respiratory hygiene / cough etiquette

32. Transmission-based Precautions Standard Precautions + • Contact • Direct (skin to skin, fecal-oral) and indirect (environmental) • Gloves, gown (if splashing, contamination is possible) • E.g. MRSA, CRE • Droplet • Large droplets: respiratory secretions, coughing, sneezing • Surgical mask within 3-6 feet of patient • E.g. Pertussis, influenza • Airborne • Pathogens suspended in air as small particles • N95, PAPR, negative pressure room • E.g. Tuberculosis, varicella

33. Hand hygiene • Perform hand hygiene: • After touching blood, body fluids, secretions, excretions, etc. • whether or not gloves were worn • Immediately after removing gloves • Between patient contacts • Antimicrobial soap and water / friction • Alcohol-based hand rubs • Caveat: Organic material inactivates alcohol, must wash to remove visible soil

34. Standard Precautions: Injection Safety • Practices that prevent contamination during preparation and administration of all parenteral medications CDC 2007 Guideline for Isolation Precautions www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf

36. 18 Outbreaks of Viral Hepatitis Associated with Unsafe Injection Practices in Ambulatory Settings, 2001-2011 • 2 common unsafe injection practices that resulted in BBP transmission (both can transmit infections, even if the needle is changed): • Reuse of a syringe for multiple patients • Accessing a medication vial used for multiple patients Source: CDC

37. CDC One and Only Campaign • Promote safe injection practices • Provide information to clinicians in all types of healthcare settings Unsafe injection practices = never events • Injection safety training videowww.oneandonlycampaign.org/videos/Default.aspx • CDC injection safety FAQs from providerswww.cdc.gov/injectionsafety/

38. Cleaning and Disinfection/Sterilization: Reusable Medical Equipment • Reusable medical equipment must be appropriately cleaned and disinfected / sterilized prior to each use • Glucometers, other point of use devices • Endoscopes • Surgical instruments • Assign responsibilities and ensure annual competency training and education • Use appropriate PPE when handling/reprocessing contaminated equipment

39. Endoscope Reprocessing Breaches Reported to MDH, 2010-2011

40. MDH Poster Key Endoscope Reprocessing Steps www.health.state.mn.us/divs/idepc/dtopics/infectioncontrol/scope/

42. Antimicrobial Stewardship Goals

43. Antimicrobial StewardshipStrategies Right drug/dose/duration Obtain cultures/avoid empiric prescribing if possible Adjust empiric prescribing/stop antibiotic based on lab results

44. Antimicrobial Stewardship Programs • Provide the infrastructure to preserve antimicrobials • Promote patient safety • Can be implemented in any healthcare setting – from the smallest to the largest • CDC: Get Smart About Antibiotics in Healthcare http://www.cdc.gov/getsmart/healthcare/?s_cid=dhqp_002

45. Minnesota Guide to a Comprehensive Antimicrobial Stewardship Program New! www.health.state.mn.us/divs/idepc/dtopics/antibioticresistance/index.html

46. Resources Available From the MDH Website http://www.health.state.mn.us/

47. Two components: • SAFE = Infrastructure to support SSI Prevention Strategies • SSI Prevention Strategies = “CUTS” www.health.state.mn.us/divs/idepc/dtopics/hai/ssi/toolkit/index.html

48. SAFE CUTS • SSI Prevention Team • Champion, inter-disciplinary team • Access to Information • Audit prevention steps (e.g., a pre-, intra-, post-procedure checklist • Measure outcomes (National Healthcare Safety Network [NHSN]) • Facility Expectations • Process for speaking up and “stopping the line” • Communicate expectations to all providers: pre-op evaluation for infections; postpone elective surgery until infection resolved • Education • Clinicians and staff • Patients (pre-op, post-op)

49. SAFE CUTS (cont.) • Cleaning surgical equipment/environment • Appropriate use of immediate use sterilization • Undergoing surgery • Pre-op: antibiotics, pre-warming, blood glucose, skin prep • During: Keep OR door closed, maintain normothermia • Post-op: Normothermia, blood glucose, patient /family education • Team Accountability/Communication • pre-op briefing, surgical checklist to track SSI prevention measures • Staff • Expectations: hand hygiene, illness, surgical attire

50. SAFE From CDI www.health.state.mn.us/divs/idepc/diseases/cdiff/toolkit/index.html