How to Ace the CIC exam? AH-IP group meeting

1. How to Ace the CIC exam?AH-IP group meeting May Abdalla, MPH, CIPHI, CIC

2. Certification Test Do I need to give you reasons on why should get certified? What should you do before taking the test? Have good attitude Keep your goals in mind Be ready Keep it a secret Or Not

3. 2014 Examination content outline • 150 questions -----wait 15 questions will not be counted

4. Questions distribution • 1. Identification of Infectious Disease Processes (18) • 5. Management and Communication (Leadership) (16) • 6. Education and Research (14) • 2. Surveillance and Epidemiologic Investigation (38) • 3. Preventing/Controlling the Transmission of Infectious Agents (39)

5. Infection Prevention in Special Populations Know your exceptions first

6. Elderly population • “Everything You Ever Need to Know About Infection Control” • Inf. = • Dose x Time x Virulence • Host Defense

7. Diminished host resistance GI system-saliva, esophageal emptying, loss of gastric acid, changes in fecal flora, >pathogens due to decreased intestinal motility GU system-structural changes cause decreased urine, relaxation female pelvic floor, reduced bladder emptying, bladder outlet obstruction, catheters Skin & mucosal surfaces-thinning of dermis, loss of elasticity, colonization due to altered skin pH, decreased sweat, damage to blood vessels, lower levels of oxygen increasing skin breakdown, peripheral neuropathy from chronic disease Diminished functions of phagocytic polymorphonuclear(PMN) leukocytes, Diminished function of T and B lymphocytes

8. Questions time Question #2 What factors increase the risk for aspiration in the elderly? 1. Drugs which decrease saliva 2. Depression of foreign cell clearance mechanisms 3. Delayed esophageal emptying 4. Weakened cough 5. Increased chest rigidity A. 1, 2, 3, 5 B. 2, 3, 4 C. 1, 2, 3, 4 D. All of the above Question #1 When an elderly person is hospitalized and on bed rest, which of the following will increase his/her risk of infection? A. Thinning of epidermal and dermal layers B. Increases in subcutaneous fat C. Higher levels of oxygen in the tissues D. Rigid connective tissue Question #3 All of the following are changes in activity of the T cells or B cells, which effect immunity associated with the elderly, EXCEPT • Delayed hypersensitivity • Defense against foreign antigens • Increased serum level of IgG and IgA • Shortened T-cell life in post-mature life

9. More questions Question #4 Pneumonia in the elderly in the LTCF is usually identified by: • Sputum cultures • Chest X-ray • Rapid onset chills, fever, and increased respiratory rate • Heavy productive cough Question #5 Elderly patients with active or re-activated pulmonary tuberculosis: • Have fewer and less marked symptoms • Do not have a cough, weight loss, or fever • Always have a negative PPD skin test • Have a larger area of induration than a younger person

10. Immunocompromised person

11. Question time ??? Question # 7 When investigating why several oncology patients have developed pneumonia, you discover that the one factor they all have in common is they each take long showers as opposed to being bathed by the staff. What organism would you suspect to be involved? A. Legionella B. Pneumococcal C. Influenza D. Varicella Question #6 A female being treated for breast cancer has a WBC of 2.3. Her physician has been aggressive in treating every potential infection she has had. She is currently on an antibiotic for a bloodstream infection from Staphylococcus epidermidis. She now has a fever of 100.4 F. What could this possibly indicate? • Her intravenous sites should be inspected frequently. • She may have neutropenic fever and no real infection. • She may be developing a fungal septicemia and need more blood cultures. • She has a “drug fever” and the antibiotics should be stopped.

12. Few more questions?? ready Question # 9 You received a call from a young man who think he is exposed to HIV. His ELISA test was negative, he wants to know how long it will be before positive antibodies show up on his test if he has been infected? • 6 months • 1 to 3 months • 12 months • 3 weeks Question # 8 When an AIDS patient is admitted with possible pneumonia, the physician who is a general practitioner orders airborne isolation. What is the correct response? • PCP is not transmitted person-to-person and does not require isolation. • A TST skin test should be placed to determine if patient may have TB. • A sputum specimen should be collected for AFB daily x 3, if TB is suspected. • If the chest x-ray is clear, isolation can be discontinued.

13. Immunocompromised person

14. Let us practice more Question # 10 Your patient received extensive burns over 3 weeks ago and has infection in the skin graft regions. When looking for sources of infection in the patient’s environment, the following would be suspected: 1. Vase of fresh cut flowers in room 2. Need for sterile linen instead of clean 3. Water used for hydrotherapy 4. Improper hand hygiene of visitors 5. Improper topical antimicrobial used A. All of the above B. 1,2,3 C. 2,3,4 D. 1,3,4

15. Immunocompromised person

16. Are you ready for more questions? Question 11: You are investigating an ICU patient which has developed a VRE infection at his chest tube insertion site. The previous patient in that bed had a VRE abdominal wound infection. Your FIRST action would be: A. Culture all staff who cared for both patients B. Culture the room surfaces C. Question staff about equipment cleaning practices D. Send both patient cultures for pulse field gel analysis

17. Are you ready for more questions? Question 12: An example of an Iatrogenic risk factor for infection which ICU patients have would be: A. Gunshot wound B. Congestive heart failure C. Inherited immunity deficits D. Corticosteroid therapy for joint pain Question 13 Example(s) of environmental factors which raise the risk of infection for ICU patients include: A. Staff are working short because of vacations B. Generic medications are substituted for brand name ordered C. Charge nurse has to take patients to keep assignments fair D. All clean surgical patients are kept in one unit together

18. Immunocompromised person

19. Questions time???? Question # 14 A 12 month old infant is admitted with severe coughing which sometimes caused vomiting and episodes of apnea. The child was closely examined by 2 nurses and the ER physician. The next day, lab results indicate Pertussis. What do you do? A. Nothing, it is too late to treat and most employees are still immune from previous DPT shots B. Order antibody testing on exposed personnel to see if they are immune. C. Offer all exposed personnel antimicrobial prophylaxis D. Notify the local health dept. to follow your employees for symptoms. Question# 15 A 6 year old child is admitted with signs & symptoms of Rubella. Which of the following would be important to do? 1. Check on immunization history 2. Contact local health dept. for case investigation 3. Check to see if child has traveled or been in contact with someone from foreign country 4. Check contact employee health files to ensure immunity 5. Order IgM and IgG Rubella titers on the child A. 1, 2, 4, 5 B. 1, 3, 4, 5 C. 2, 3, 4, 5 D. All the above

20. Behavior Health • Milieu Infections • Lack of patients medical history • Potential violence that may lead to injuries and blood exposure • Safety issues related to alcohol hand sanitizer • Manifestations of mental illness • Side effects of psychotropic meds • Poor hygiene or lack of • Electroconvulsive therapy • Off sire healthcare • Parasite infestations Unless accredited facility, IP program may not be strong. Older building structures Lack of medical care and laboratory delay Lock down unit, difficult to implement isolation

21. Ambulatory Care • Same infection principles applied • Based on specific population and services • Follow up is more difficult • Prison health clinics • Outpatient Surgery • Dental offices • Urgent care • Student health • Family practice • Plastic surgery • Pain management IP role: Communication with acute care Surveillance Disinfection and sterilization Med. preparation Specimen handling Patient triage

22. Home Health Cross infection due to increase transfers and admission from different facilitites Medical equipment used in care for the patients Outside suppliers such as infusion therapy Infection prevention challenges includes: • Difficult to provide annual training • Lack of training resources

23. Home Health Intrinsic: age, underlying disease, nutrition, immunity, substance abuse, pregnancy Intrinsic: invasive procedures, socioeconomic status, lifestyle, surgery, radiation therapy, chemotherapy. Infection prevention challenges includes: • Poor personal hygiene • Contaminated supplies • Rodent/insect infestations • Infectious diseases of family • Exposure • Poor sanitation • Lack of training resources

24. Homecare infection prevention factors Trach, catheters, suctions, aerosol delivery devices Implanted devices (intrathecal reservoirs) Wound care management (dressing disposable) Dialysis Nursing bags

25. Dialysis • Common infections related to the access site, bacteremia, and peritonitis • Risk of infection due to underlying conditions, access to sterile areas, contamination during the procedure or component of the system. (blood borne outbreaks such as Hep B) • Prevention includes strict aseptic technique, disinfection and maintenance of equipment, adequate staff training, monitoring of procedures and system maintenance such as water cultures, follow-up with patients, and patients education such as maintaining the dialysis port

26. Practice makes perfect Question#16 When reviewing micro education with dialysis nurses, MOST common bacterial cause of vascular access site infections is: • E-coli • Staph aureus • Pseudomonas aeruginosa • Strep. pyogenes Question#17 IP chairman and IPs are reviewing IP policies and notice several areas that are performing routine culturing. In which of the following areas is routine culturing recommended: • Dialysis • Rehab • RT • Endoscopy

27. Let us do some more… Question#18 You are the director of IPD in a large teaching hospital. You learn the dialysis unit coordinated has known for a year that one of her nurses is positive for HBsAg. She does not want to move that person out of the department because she will be retiring in one year. The ultimate conclusion to this issue should be: the nurse • Need to retire, and coordinator should be reprimanded • Will need to take MLOA • Should be offered another position in another department • Can work in this department but not administer treatments Question#19 When caring for patients receiving dialysis, their risk of infection reduced by all of the following EXCEPT: • Knowledgeable, well trained staff • Strict adherence to aseptic technique during all procedures • Monitoring of patients following procedures for signs of infection • Comprehensive baseline testing of all patients for immune system deficiencies before beginning procedures

28. Let us do some more… Question#20 Which of the following organisms would be the most likely cause of viral conjunctivitis in a physical therapist who performs home care? • Echovirus • Adenovirus • Enterovirus • Herpes simplex virus Question#21 Your are consulting for IP for a home care agency abd are beeped by a home care burse while she is in the field conducting a DOT visit with a confirmed active TB 10 days ago………………..what PPE do you recommend for the home care nurse: • A fit tested respirator and gloves • A regular mask • None required • A fit tested respirator only

29. The last one Question#22 During an educational in-service to Pediatric nurses, the IP is asked how to manage a patient with CMV. The correct precautions include: • Droplet • Standard • Cohort all children with CMV • Assign non-pregnant nurses to care for CMV infected children Question#23 An outbreak of RSV occurs in the Pediatric unit. You start a descriptive study of the patient and employee population. An example of a descriptive study is a study that: • Proves causality • Includes cohort studies and case control studies • Characterizes populations by time, person, and place • Include only prevalence

30. Identification of Infectious Disease Processes Know your how's

31. Epidemiology (EPI) The study of the relationships of the various factors determining: • frequency • Distribution • of disease in a human community.

32. Terminologies Normal Flora: Anywhere out bodies contact the environment, microorganisms have set up a niche/biocommunity that is in a dynamic state through their lifetimes and ours. We carry thousands of bacteria that normally live on these surfaces (skin, GI, GU, lungs, etc.) without causing disease. Colonization usually caused by normal flora. Non-invasive No host response Infection- caused by pathogen Invasive Host response Microbial Pathogenicity: microorganisms could cause pathogenicity depending on: • Adherence characteristics • Dose • Toxin production • Virulence • Ability to elude host defenses • Genetic variation • Persistence in the environment • Viral characteristics. Toxins- Endotoxins: gram negative cell wall, not destroyed by boiling or autoclaving. Exotoxins: gram positive, more susceptible to heat but variable. It get neutralized by specific antibody.

33. Immunity Active – Naturally-acquired--resolved infection – Artificially induced--vaccination, immunization The resistance of a host to a specific agent, characterized by measurable and protective surface or antibody and by cell-mediated immune responses... Passive – Naturally-acquired--maternal antibodies – Artificially introduced--serum immune globulin

34. Immune System… • Primary organism of immune system are responsible for the defending the body from foreign and neutralize or eliminate them . Humoral – B cells – antibodies IgM, IgG,IgA, IgE Cellular-T cells (CD4, CD8), long term memory Non-specific Host defenses Complement system Phagocytic cell system

35. Normal flora and immunity Anywhere our bodies contact the environment, microorganisms have set up a niche/biocommunitythat is in a dynamic state through their lifetimes and ours We have thousands of bacteria that normally live on these surfaces (skin, GI, GU, lungs, oro-/naso-pharnyx) without causing disease

38. Question time • Q1:When investigating a food poisoning outbreak you discover that some persons began to vomit within 1-2 hours, some were nauseous, and some had delayed nausea and diarrhea. What characteristic of the pathogen explains this BEST? • 1. Virulence • 2. Dose • 3. Toxin production • 4. Persistence in environment • 5. Genetic variation • A. 2, 3 • B. 1, 4 • C. 3,4,5 • D. 1,2,3 Q2 follow ups questions….very common Learning that the food consumed was cooked immediately prior to eating, the MOST likely explanation for illness is: A. Contamination was probably utensils instead of food B. Contamination occurred during preparation C. There was no contamination D. Bacterial growth occurred while food was improperly stored

39. Q3:A patient with a feeding tube, foley catheter, central line and a tracheostomy develops a fever. Blood cultures reveal E-coli and Pseudomonas aeuroginosa, urine culture 98,000 gram negative rods. What is the most likely source? A. Central line B. Respiratory tract C. Urinary tract D. GI tract Q4 All healthcare workers should be immunized for the flu each year. What characteristic of pathogens causes this. A. Ability to elude host defenses B. Virulence C. Adherence characteristics D. Genetic variation • Q5 Which disease requires a very small inoculum of organisms to cause disease? • Dysentery (Shigella) • Salmonella • C. Campylobacter • D. Giardia

40. Let us do more • Q6 Patients with cell-mediated immunity dysfunction are susceptible to infections • attributed to pathogenic intracellular bacteria. Examples of these organisms include: • 1. Salmonella • 2. Bacteroides • 3. Listeria • 4. Staphylococcus • A. 2, 3 • B. 1, 3 • C. 1, 2 • D. 3, 4 Q7 Which immune marker represents past exposure to disease? A. IgG B. IgE C. IgM D. IgA

41. One more Q8 The TB skin test (TST) has limitations. It depends on a functioning immune system. Which system? A. Humoral B. Complement C. Cellular D. None of these

43. Microorganisms Basic Groups Viruses and prions “slow viruses” Fungi Bacteria – Gram positive – Gram negative – Aerobes – Anaerobes – Chlamydiae, Mycoplasmae, Ureaplasmae and Ricketsiae – Spirochetes – Mycobacteria Parasites: – Endoparasitic – Ectoparasitic – Unicellularprotozoans – Multicellularhelminths and arthropods

45. Other techniques in ID of organisms Lab culture medias • Blood agar- broad array of bacteria • Chocolate agar- Haemophilus, Neisseria • Lowenstein-Jensen- Mycobacterium • MacConkey- gram negative • Bile esculin- group D Strep. • Thayer-Martin- N. gonorrhoeae • Charcoal yeast- Legionella • Ziehl-Neelsen- Mycobacterium (AFB) • Light microscopy • Electron Microscopy • Specimen preparation • – Direct examination • – Differential fixed staining • Physical conditions required for growth • – Nutrition (types of media) • – Temperature (pathogens 35°C) • – Aerobe or anaerobe

46. Common Microorganisms • Gram Positive bacilli – Bacillus-anthracis – Listeria – Clostridium –tetani, difficile, perfringens • Gram Negative bacilli • Klebsiella • Proteus • Morganella • Escherichia • Salmonella • Citrobacter • Enterobacter • Pseudomonas • Stenotrophomonas • Acinetobacter • Haemophilus • Bacteroides • Shigella • Serratia Gram Positive Cocci • Staphylococcus – Aureus – Epidermidis & CoagNeg Staph • Streptococcus – Viridans – Pyogenes(Group A hemolytic) – Group B or C – Pneumoniae • Enterococcus faecalis or faecium – galinarium Gram Negative cocci – Neisseria meningitidis or gonorrhoeae – Moraxella catarrhalis

47. Common Microorganisms Acid-Fast Bacilli • Mycobacteria – Tuberculosis – Avium-Intracellulare (MAC) – Kansasii – Gordonae – Marinum – Chelonae – Fortuitum – Abscessus Viruses • Coronavirus-common colds • Cytomegalovirus • Ebola • Epstein-Barr • Hanta virus • Hepatitis A • Herpes simplex • Human Immunodeficiency • Human Papillomavirus • Human parvo B19 • Influenza • Marburg • Poliovirus • Rabies • Rubella • Varicella zoster • West Nile Fungi • Rapid growth – Aspergillus – Penicillium – Cryptococcus • Slow growth – Histoplasma – Blastomyces – Coccidioides

48. Common Microorganisms Prions- “Slow virus” • Creutzfeldt-Jakob Disease (CJD) – Spongiform encephalopathy – Proteinaceous infectious particles -no DNA or RNA – May incubate 10-30 years – Infected tissues, medical devices, transplants • CJDv – Mad Cow – bovine spongiform encephalopathy-possible shorter incubation • Kuru-related to cannibalism • GSS (Gerstmann-Straussler-Scheinker) • FFI (Fatal Familial Insomnia) Parasites • Frequently large – single cell up to 30 ft • Lab specimens often alive • Eggs, cysts, or adults • Not usually tested for • Lice, scabies, mites, worms Giardia lambia is the most important parasite because it is associated with outbreaks in daycare settings

49. Resistant organisms Resistance to antibiotics – Intrinsic-- natural and consistently inherited by the organism strain – Acquired-- results from altered cellular physiology and structure cased by changes in the genetic make-up Mechanisms of Antibiotic Resistance • Enzymatic inactivation of drug • Alter permeability barriers • Active efflux of drug from cytoplasm of bacteria • Alter target protein in cell wall • Alter cytoplasma target • Genetic mutation • Antimicrobial Use and Selective Pressure

50. Measures to Control Resistant Organisms • Antibiotic stewardship • Surveillance • Antibiograms • Appropriate use of vaccines • Appropriate isolation precautions • Hand hygiene Extended Spectrum Beta-Lactamases (ESBL) – Gram negative organisms – Enzymatic destruction • Beta-lactamase enzymes destroy the beta-lactam ring so that the antibiotic cannot bind to the PBP and interfere with cell wall synthesis Resistant Organism: ESBL • Organisms most commonly tested • K. pneumoniae • K. oxytoca • E. coli 3rd generation cephalosporins: cefpodoxime,ceftazidime, aztreonam, cefotaxime, ceftriaxone