Infection Control Measures in the ICU: A day in the life of a bacterium in the ICU

1. Infection Control Measures in the ICU:A day in the life of a bacterium in the ICU B. Taylor Thompson, MD Director, MICU Massachusetts General Hospital Associate Professor of Medicine Harvard Medical School tthompson1@partners.org

2. Presentation Outline Nosocomial transmission • Where bacteria live and how they get around • Infection Control in the ICU: • Central role for and hygiene • Review the MGH experience

3. WHO Global Safety Challenge First Target (2005-2006) • Health Care Associated Infections • Hand Hygiene as cornerstone

4. 5 Essential Steps for Cross Transmission Pittet et al Lancet Infect Dis 2006

5. ICU patients are rapidly colonized with pathogenic bacteria • Skin colonized in hours to days • Staph. aureus, Proteus mirabilis, Klebsiella spp. present @ 100-106 CFU /cm2 skin • Perineal/inguinal > axilla > trunk > upper extremities and hands • Dialysis/CRF, diabetes, dermatitis, broad spectrum Abx increase risk • Patients shed 106 squames/day -> widespread contamination of the room Reviewed in Pittet et al Lancet Infect Dis 2006

6. 5 Essential Steps for Cross Transmission  Pittet et al Lancet Infect Dis 2006

7. Transmission to Hands from Skin and Environment Pittet et al Lancet Infect Dis 2006

8. Transfer to the hands of health care workers (HCWs) hands: I • “Clean Activities” (lifting, taking radial artery pulse, measuring blood pressure) • Up to 100-1000 cfu from HCWs hands • HCWs intercepted before hand wash in MRSA colonized patient • 17% of worker’s gloves positive Phillips, BMJ 1977; McBride, J Hosp Inf 2004

9. Transfer to the hands of health care workers (HCWs) hands: II • Surveillance cultures of HCWs hands in ICU • 21% of MDs; 5% of nurses positive (n=328) • Serial Cultures of NSICU HCWs hands • 100% positive for GNR and 64% positive for staph aureus at least once • Rings, artificial or long nails, dermatitis increase frequency of hand contamination of HCWs Daschner, J Hosp Inf 1988; Maki, Ann Int Med 1978; Trick, Clin Inf Dis 2003

10. More contamination with more care Pittet, Arch Int Med 1999

11. Contamination of Healthcare Workers with VRE during Routine Patient Examinations At least one site 33/49 (67%) Gloves (Hands) 31/49 (63%) Gowns 18/49 (37%) Stethoscopes 15/49 (31%) All three sites 12/49 (24%) Stethoscope after wipe 1/49 (2%) Zachary, Infect Control Hosp Epidemiol. 2001

12. 5 Essential Steps for Cross Transmission   Pittet et al Lancet Infect Dis 2006

13. Bacterial Survival times on hands • Acinetobacter spp 60 min • E. coli 6 min (mean) • Klebsiella spp 2 min (mean) • VRE 60 min • Pseudomonas sp 30 min; 180 in sputum • Rotavirus 16% survive 20 min; 2% survive 60 min

15. Contamination of ICU Patient Charts • Sterile swab of outside of binders/charts kept outside the ICU room Percent of ICU charts culture positive by organism Panhotra Am J Infect Control 2005

16. 5 Essential Steps for Cross Transmission    Pittet et al Lancet Infect Dis 2006

17. Hand washing compliance rates by occupation Pittet D et al. Ann Intern Med 1999; 130:126

18. 5 Essential Steps for Cross Transmission     Pittet et al Lancet Infect Dis 2006

19. MGH Nosocomial MRSA 1995-1999

20. Strategies to decrease transmission • Proven or Proposed Strategies • Antibiotic stewardship • Proper hand hygiene • Cohorting patients • Reducing LOS • Gowns and gloves • Isolation of patients • Appropriate staffing ratios • Antibiotic crop rotation • Surveillance cultures • Decolonization of patients (chlorhexidine body washes, muciprocin) • Decolonization of health care worker carriers • Paucity of RCTs on efficacy of individual approaches • Efficacy of an individual approach may vary by pathogen • Near eradication of a pathogen from a hospital (or a country) requires a bundle of approaches (eg. “Search and Destroy” in the Netherlands)

21. Compulsive Antibiotic Prescribing (CAP) • CAP is a widespread and serious affliction • First year medical students are free of the disease • Interns and first year residents are severely afflicted…life-long habit difficult to break • CAP is supported by a well organized group of antibiotic pushers • Antibiotics Anonymous • Self help group, available 24 hours, will talk you through the urge to prescribe more than two antibiotics, other abuses Lockwood et al, NEJM p465-466, 1974

22. Is isolation safe for the patient? • Cases: Consecutive patients admitted and isolated for MRSA • Controls: Patients in the same room immediately before and after a case • Similar baseline characteristics • Cases • More likely to have unrecorded vital signs, absent MD progress notes, and to complain about their care • Twice the rate of preventable adverse events • Similar mortality (17% cases vs 10% controls, p=0.16) Stelfox , JAMA 2003

23. Communication Campaign

24. MGH Hand Hygiene (HH) Campaign • 2000 HH Task Force (D. Hooper and P. Wright) • Cal stat dispensers hospital wide • 2002 Poster/Educational Campaign • 2004 • 8% wash before contact, 48% after contact • HH Champions on each floor -> Pizza • New Poster Campaign • Monitoring and feedback of HH rates by unit/floor, RN/MD

25. MGH Hand Hygiene Campaign • 2005-2006 • Benchmark against peers (more peer pressure) • “On the spot” Coffee Central coupons • Patients as advocates: patient learning center • 2007 • HH Quality incentive program: if rates of HH before and after patient contact > 90% on a given floor/ICU, monetary bonus paid at years end to RNs, MDs. Rates/reminders sent to units monthly

26. MGH Quarterly Hand Hygiene rates: 2004-07 Before contact After contact *with the patient or patient’s environment High: 93% High: 90% 47% 8% JCAHO expectation: 90% Target for 2007: 90% MGH goal: 100%

28. Conclusions • Nosocomial transmission of pathogenic bacteria creates a major health burden • Multifaceted interventions are needed for high level control: proper hand hygiene is the cornerstone of prevention efforts • Isolation of patients may place them at risk for errors of omission

29. Thank you