Hospital acquired infections from evidence to local practice and outcomes
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Hospital Acquired Infections: From Evidence to Local Practice and Outcomes. Adrienne Green, MD Associate Professor, Division of Hospital Medicine Associate Chief Medical Officer. Objectives. Review the adverse outcomes associated with HAIs

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Hospital Acquired Infections:From Evidence to Local Practice and Outcomes

Adrienne Green, MD

Associate Professor, Division of Hospital Medicine

Associate Chief Medical Officer


  • Review the adverse outcomes associated with HAIs

  • Describe the internal and external initiatives, mandates for reducing HAIs

  • Focus on prevention

  • Highlight UCSF programs, challenges and successes

Spectrum of HAIs

  • Catheter related bloodstream infection

  • Clostridium difficile

  • Ventilator associated pneumonia

  • Catheter associated UTI

  • Surgical site infections

  • MRSA

  • VRE

  • MDR pathogens

Focus for today


  • Clostridium difficile

Scope of the Problem

  • 5-10% hospitalized patients develop a HAI

  • 1.7 million HAI per year in U.S.

  • Nearly 100,000 deaths per year in U.S.

  • Estimated $5 billion additional cost

    Many are preventable!

Krevens et al. Pub Health Rep 2007

Deaths Due to HAI

Other 11%

UTI 13%

BSI 31%

PNA 36%

SSI 8%

Krevens et al. Pub Health Rep 2007

Scope of the ProblemOutcomes and Cost

Perencevich et al. 2007

Scope of the ProblemExternal Initiatives and Mandates

Scope of the ProblemCalifornia Initiatives and Mandates

Scope of the ProblemUCSF CRBSI Data


Scope of the ProblemUCSF CRBSI Data


Scope of the ProblemUCSF VAP Data

Catheter Related Bloodstream Infections

Annual Patient Stays in the 6000 Acute Care Hospitals and Associated ICUs in the United States

Wenzel R and Edmond M. N Engl J Med 2006;355:2781-2783

HAI case: Part 1

A 60 y/o M with h/o ETOH use is admitted to the ICU with a rapid upper GI bleed. An IJ central line is placed for pressor administration. He is intubated in order to perform an EGD. He develops alcohol withdrawal and cannot be extubated after the procedure. Four days later, the patient’s withdrawal has improved but he develops a fever to 39.3.

HAI case: Part 1

The patient is doing well from a respiratory standpoint, on FiO2 of 0.4, no secretions, no new infiltrates on CXR. IJ central line insertion site is clean. UA is negative. Vancomycin is empirically started for central line infection and 24 hours later blood cultures (1 from line and 1 peripheral) are positive for Staph epi.

Potential Sources of CRBSI

  • Contamination by patient’s own skin flora

    • Extraluminal contamination

    • Most common in short-duration catheters

    • Tends to occur early

    • Related to insertion

  • Contamination of device hub by medical personnel

    • Intraluminal

    • Most common in long-duration catheters

    • Increases as access rate increases

    • Tends to occur late

    • Related to line maintenance

  • Hematogenous seeding- rare

  • Introduction of contaminated infusate-rare

Risk Factors for CRBSI

  • Emergent insertion

  • Site: femoral > IJ > SC

  • Long hospital stay before line insertion

  • Line > 6 days

  • Neutropenia

  • TPN

  • Poor care- excessive manipulation, insertion/maintenance technique

CRBSI PreventionThe Big Five*

  • Hand hygiene

  • Avoid femoral site

  • Maximum barrier precautions

  • Chlorhexidine skin prep

  • Remove unnecessary catheters

    * Evidence-based and CDC recommendations

An Intervention to Decrease CRBSI in the ICU

  • 108 ICUs in Michigan

  • Education re: 5 prevention measures

  • Checklist

  • Supply carts and kits

  • Permission to stop procedure if not compliant

  • Discuss need for line at daily rounds

  • Line rate feedback to providers

Pronovost et al. NEJM 2006

CRBSI PreventionThe antibiotic/antiseptic coated catheter

Ramritu et al. Am J Inf Control 2008

Not Recommended for CRBSI Prevention

  • Routine line change

    • Doesn’t decrease infection and increased complications

  • Changing lines over a wire

CRBSI Prevention at UCSF

  • Central line insertion

    • 5 interventions as above

    • CVC Insertion Checklist

    • CLIP note

    • Routine U/S guidance

  • Daily review of CVC necessity on rounds/discharge checklist

  • Many new line maintenance practices

UCSF CLIP NoteRequired by State of CA

CRBSI at UCSFHard work and Success!


Antibiotic coated catheters

Central line insertion module

More focus on line maintenance

Most infections at >7 days duration

Using friction, “Scrub the hub” or injection cap/port for a count of ten

CRBSI PreventionComing Soon

Central Line Module

The Business Case for CRBSI Prevention

  • FY08 = 88 CRBSI

  • FY09 (annualized from first 7 mo) = 55 CRBSI

  • Conservative data indicates CRBSI costs

    • $18,432 (mean)

    • 12 excess days LOS (mean)

  • Savings from 33 avoided CRBSI

    • $608,256

    • 396 days

HAI Case: Part 2

The patient’s fever resolved after the line was removed and he was placed on vancomycin. He was extubated and on HD #6 was transferred out of the ICU.

Later that day you receive a call that he has had 6 episodes of watery diarrhea that “smells like c. diff.” You institute the appropriate precautions and send a stool sample for c. diff. The test returns positive. Diarrhea resolves 2 days after institution of oral metronidazole and he transfers to a SNF for rehabilitation before going home.

Clostridium difficileA quote from Mr. S

“I wouldn’t wish this illness on anybody. C.difficile is one of the most terrible things that I’ve been dealing with in my whole life, and I’ve dealt with a lot of things since my kidney transplant. I hope that this latest regimen of pills will cure me– because I’m going out of my mind.”

Clinical Crossroads. JAMA. March 4, 2009

Clostridium difficile

“Stomach Bug Crystallizes an Antibiotic


New York Times April 14, 2009

Clostridium difficile

  • Gram positive, anaerobic, spore forming bacillus

  • Spores stable up to 5 months

  • Toxins A and B

  • 1-3% healthy adult colonized

  • 15-25% w/ recent hospitalization colonized

  • ~20% of antibiotic assoc diarrhea

C. diff: Scope of the ProblemIncreasing Cases

Increase at greater rate in the elderly

C.diff in patients discharged form U.S. Short Stay Hospitals

C. diff: Scope of the ProblemIncreasing Cases

* CDC data

C. difficile Toxin Test Positive Cases in Adult and Pediatric Patients, Moffitt-Long Hospitals 1994 – 2008Positive Tests from Specimens Collected in In-Patient Locations

Zosyn shortage; shift in antibiotic use patterns

Hand Hygiene campaign; DDT; Precautions Monitoring

Patients having stools positive for C. difficile collected from more than one location are represented here only once.

C. diff: Scope of the ProblemIncreased Virulence

  • New virulent strain (BI/NAP1/027)

    • Produces toxins A and B

    • Production of binary toxin

    • Hypersporulation

    • Fluoroquinolone resistance

States with BI/NAP1/027 strain of C. difficile (N=40), October 2008

No cases at UCSF





C. diff: Scope of the ProblemIncreased Mortality and LOS

Kenneally et al. Chest 2007

C. diff: Scope of the ProblemIncreased Mortality and LOS

  • Increased Mortality

    • 6.9% at 30 days

    • 16.7% at 1 year

  • Increased LOS

    • 2.6-4.5 days

Dubberke et al. Inf Cont Hosp Epid 2008

C. diff: Scope of the ProblemCost

  • Estimated annual cost in U.S. $1-3 billion

Dubberke et al. CID 2008

Risk Factors

Impaired resistance to colonization

Antibiotics: clinda, cephalosporins, amp, fluoroquinolones and more

Risk of exposure

Host factors

increasing age


Prevention of C. Difficile Infection

Prevention Measures



Infection Control


Hand washing with soap and water

spores resistant to alcohol

Gloves for contact

Single room or cohort

spores 50% of sites in rooms occupied by pt with c.diff

Dedicated equipment


spores resistant to most disinfectants

Gowns- no data, CDC recommends

Infection Control: What works?

Hand Washing Compliance at UCSF


Antibiotic Stewardship

  • Antibiotic associated risk factors

    • Cephalosporins → extensive disruption of GI flora, “work horse” antibiotic, c.diff uniformly resistant

    • Clindamycin → clinda resistant strain in ’70s

    • Multiple antibiotics

    • Prolonged antibiotics

  • Restrict antibiotics

  • Education, audit and feedback

Other Prevention Measures

  • Consider decreased use of H2-blockers and PPIs

    • Acid kills the vegetative form of c.diff

    • Incidence of acid blocker use and c.diff increasing in parallel

  • Probiotics being studied


≥ 3 unformed stools in ≤ 24 hours

Created 5/07

Revised 10/07, 11/07, 05/08, 11/08

* From the lab manual re C. difficile testing: “Only liquid or unformed stools will be accepted. Assays should be ordered only on patients who manifest persistent diarrhea, have recently received antimicrobial or antiviral therapy, and are not receiving stool softening agents.”

Initiate and DocumentCONTACT PRECAUTIONS for patient withDIARRHEA (No MD order required)

patient < 1 year old

Contact Precautions until diarrhea resolves

patient ≥ 1 year old

Admitted < 3 days ago?

Admitted ≥ 3 days ago?

  • MD: Consider testing for infectious etiologies:

    • Bacterial

  • Viral

  • Parasitic

  • C. difficile* if pt has hx of antibiotic use

  • See branch below for patients with known chronic diarrhea

  • Send ONE stool for C. difficile test*

  • Pediatric patients only: Also send ONE stool for rotavirustest


Includes result: “NEGATIVE toxin assay. Positive somatic antigen assay.

(Interpretation:NEGATIVE TEST - not consistent with C. difficile induced disease.)”

(Maintain Contact Precautions until results are FINAL)


C. difficile positive: Continue precautions until diarrhea resolves**.

Rotavirus positive: Continue Contact Precautions for duration of hospitalization or until diarrhea resolves and one rotavirus test is negative.


Consult Isolation Precautions table for specific organism isolated for precautions discontinuation criteria

Has diarrhea resolved? **(e.g. patient does not meet the above definition of diarrhea)


  • D/C precautionsand retest weekly for C. difficile (and rotavirus for pediatric patients) - no isolation required while tests are negative

  • Reinstitute Contact Precautions and retest ifsignificant clinical change

  • Reinstate Contact Precautions if stool becomes positive for C. difficile or rotavirus.

  • YES – continuing OR chronicdiarrhea **

    Has patient been on antibiotics in the past 6 weeks?


    Is patient on lactulose OR chemotherapy?


    May D/C Precautions (No MD order required)

    Precautions after Treatment?

    • Precautions until formed stool x 2days or return to normal stooling pattern

    • No need to retest after treatment unless recurrent symptoms

    • No benefit shown to instituting precautions for carriers


    • HAI are frequent and associated with poor outcomes

    • An ounce of prevention……

    • You can help

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