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
Adrienne Green, MD
Associate Professor, Division of Hospital Medicine
Associate Chief Medical Officer
Many are preventable!
Krevens et al. Pub Health Rep 2007
Krevens et al. Pub Health Rep 2007
Perencevich et al. 2007
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
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.
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.
* Evidence-based and CDC recommendations
Pronovost et al. NEJM 2006
Ramritu et al. Am J Inf Control 2008
Antibiotic coated catheters Associated ICUs in the United States
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 tenCRBSI PreventionComing Soon
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.
“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
“Stomach Bug Crystallizes an Antibiotic
New York Times April 14, 2009
Increase at greater rate in the elderly
C.diff in patients discharged form U.S. Short Stay Hospitals
* CDC data
C. difficile Associated ICUs in the United States 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.
No cases at UCSF
Kenneally et al. Chest 2007
Dubberke et al. Inf Cont Hosp Epid 2008
Dubberke et al. CID 2008
Risk Factors Associated ICUs in the United States
Impaired resistance to colonization
Antibiotics: clinda, cephalosporins, amp, fluoroquinolones and more
Risk of exposure
ImmunocompromisedPrevention of C. Difficile Infection
Hand washing with soap and water Associated ICUs in the United States
spores resistant to alcohol
Gloves for contact
Single room or cohort
spores 50% of sites in rooms occupied by pt with c.diff
spores resistant to most disinfectants
Gowns- no data, CDC recommendsInfection Control: What works?
DIARRHEA Associated ICUs in the United States
≥ 3 unformed stools in ≤ 24 hours
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?
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)
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)