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Infection Prevention 2012: In Defiance of the Post-Antibiotic Era March 15, 2012. Allan J. Morrison, Jr., MD, MSc, FACP, FIDSA FSHEA Inova Health System Epidemiologist Chairperson, Infection Control Committee Inova Fairfax Hospital Professor and Distinguished Senior Fellow

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infection prevention 2012 in defiance of the post antibiotic era march 15 2012

Infection Prevention 2012: In Defiance of the Post-Antibiotic EraMarch 15, 2012

Allan J. Morrison, Jr., MD, MSc, FACP, FIDSA FSHEA

Inova Health System Epidemiologist

Chairperson, Infection Control Committee

Inova Fairfax Hospital

Professor and Distinguished Senior Fellow

School of Public Policy, George Mason University

Clinical Assistant Professor of Medicine

Georgetown University Hospital

disclosures
DISCLOSURES

Speaker’s Bureau with the following entities: Care Fusion, Cubist, Glaxo-SmithKline, Pfizer, Ortho-McNeil, Merck, Sage

No mention of investigational nor

off-label usage will be employed in this program

nosocomial infections
NOSOCOMIAL INFECTIONS
  • Historical derivation
    • Nosocome: Rabelais (circa 1340)

“ . . . so they took the wounded soldiers to the great nosocome . . . ”

    • “Castle-acquired” infections

Ann Int Med 2002;137:665

most prevalent
MOST PREVALENT

CRBSIs and SSIs:

occur when skin is incised

Weinstein RA. Nosocomial infection update. Emerg Infect Dis. 1998;4(3):416-420.

infection control in the modern era history
INFECTION CONTROL IN THE MODERN ERA: HISTORY
  • 1970s: “KARDEX” system
    • Whole house/body site surveillance
    • Data prospectively gathered,

retrospectively analyzed

    • Created objective methodology
  • SENIC study
    • First large study to demonstrate characteristics

of “efficacious” IC program

    • ICP/250 beds, organized surveillance, SSI

feedback to surgeons, trained epidemiologist

nosocomial infections preventables
NOSOCOMIAL INFECTIONS : PREVENTABLES
  • SENIC (1971-1976)
    • 6% NI preventable by minimalinfection control efforts
    • 32% NI preventable by well-organized and highly effective infection control programs

Am J Epid 1985;121:182

  • Meta-analysis of interventional studies (N=25)
    • 66% reduction (15.18.3/1000 C-D)

CIN Perf Qual Hlth Care 1998;6:172

    • 46% reduction (3217.4/1000 C-D)

Am J Inf Control 1999;27:402

J Hosp Inf 2003;54:258

infection control in the modern era history1
INFECTION CONTROL IN THE MODERN ERA: HISTORY
  • 2000 - 2010
    • Emergence of evidence-based data leading to “bundles”
    • VAP, CRBSI, Sepsis, CDAD
    • (Variably) implemented but NI rates 
  • 2011 - Future

Where do we go from here?

human bacterial interface
HUMAN: BACTERIAL INTERFACE
  • Total human cells/person ~ 1013
  • Total colonizing microbes ~ 1014

. . . We are outnumbered 10:1!

NEJM 2010;362:75

eskape reference

ESKAPE Reference:

J Infect Dis 2008; 41: 327

infection control in the modern era blueprint for failure
INFECTION CONTROL IN THE MODERN ERA: BLUEPRINT FOR FAILURE
  • Current paradigm:

 MDRO (community, nosocomial)

 Transmission within facilities

 Colonization,  infection,  mortality

 ABX

pressure

  • Hand hygiene: poor compliance
  •  Respect for isolation protocols/barriers
infection prevention four pillars
INFECTION PREVENTION: (FOUR) PILLARS

*De-populate the patient

*De-populate the space

*De-instrument the patient

*De-escalate the ABX

fole

infection prevention four pillars1
INFECTION PREVENTION: (FOUR) PILLARS

*De-populate the patient

*De-populate the space

*De-instrument the patient

*De-escalate the ABX

fole

infection control and chg blueprint for success
INFECTION CONTROL AND CHG: BLUEPRINT FOR SUCCESS

CENTRAL VENOUS CATHETERS

PERIPHERAL VENOUS CATHETERS

PATIENT BATHING PROTOCOLS

PREOPERATIVE PATIENT SHOWER

OPERATIVE TEAM HAND SCRUB

BLOOD CULTURE SKIN PREP

OPERATIVE SITE SKIN PREP

slide19
PREVENTION OF CATHETER-RELATED INFECTIONS IN THE ICU: A PROSPECTIVE RANDOMIZED TRIAL OF 2% CHG/70% IPA VERSUS 10% POVIDONE-IODINE

10.6

7.7

Infection Rates per 1000 Catheter Days

P= 0.05

P= 0.015

1.3

1.3

Catheter-Related Bloodstream Infections

N = 82

Primary Bloodstream Infections

N = 82

Catheter-related bloodstream infection: Isolation of identical organisms from blood cultures and semi-quantitative catheter cultures with no other identified source of infection.

CDC primary bloodstream infection: Pathogen cultured from one or more blood cultures; organism cultured from blood is not related to an infection at another site. Patient has at least one of the following signs and symptoms: fever (>38°C). chills, or hypotension and positive skin contaminant found in blood cultures, OR positive antigen test with signs and symptoms of infection not related to another site.

Kelly R, et al. Prevention of infections related to central venous catheters and arterial catheters in intensive care patients: a prospective randomized trial of chlorhexidine gluconate (CHG) versus povidone iodine (PI). 15th Annual Scientific Meeting of the Society for Healthcare Epidemiology of America; April 9-12, 2005; Los Angeles, CA. Abstract 165.

chg central venous catheter cvc
CHG: CENTRAL VENOUS CATHETER (CVC)
  • P/R trial of CVC insertion (IJ, SC)
    • 5% Povidone-Iodine/70% ethanol
    • 0.25% CHG/4% benzylic alcohol
    • 2 x 30 second application (pre-insertion) then Q 72o@ dressing change
  • Results: PI-ACHG-AP-value

N 242 239

Catheter colonization 22.2% 11.6% 0.002

CR-BSI 4.2% 1.7% 0.09

  • RF for catheter colonization IJ site, PI

Arch Int Med 2007;167:2066

infection control and chg blueprint for success1
INFECTION CONTROL AND CHG: BLUEPRINT FOR SUCCESS

CENTRAL VENOUS CATHETERS

PERIPHERAL VENOUS CATHETERS

PATIENT BATHING PROTOCOLS

PREOPERATIVE PATIENT SHOWER

OPERATIVE TEAM HAND SCRUB

BLOOD CUTLTURE SKIN PREP

OPERATIVE SITE SKIN PREP

chg prep peripheral ivs
CHG PREP: PERIPHERAL IVs
  • P/R trial comparing:
    • 2% chlorhexidine gluconate - plus 70%

isopropyl alcohol (CHG-IA)

    • 70% isopropyl alcohol (IA)
  • Results:

CHG-IAIAP-value

N 91 79 --

X dwell 2.3D 2.2D NS

Tip Cx  20% 49% <.001

  • Skin disinfection with CHG-IA prior to PIV

insertion associated with  TIP CX 

ICHE 2008;29:963

infection control and chg blueprint for success2
INFECTION CONTROL AND CHG: BLUEPRINT FOR SUCCESS

CENTRAL VENOUS CATHETERS

PERIPHERAL VENOUS CATHETERS

PATIENT BATHING PROTOCOLS

PREOPERATIVE PATIENT SHOWER

OPERATIVE TEAM HAND SCRUB

BLOOD CULTURE SKIN PREP

OPERATIVE SITE SKIN PREP

chg bathing icu
CHG Bathing: ICU
  • 52 wk/cross-over trial
    • 22-bed MICU (Cook County Hospital)
    • Daily CHG bathing (impregnated washcloth) vs. soap/water
  • Results:

Soap/WaterCHGP-value

N (pt-days) 2119 2210

Primary BSI 10.4 4.1<.01

(per 1000 pt-days)

Arch Int Med 2007;167:2073

chg bathing icu1
CHG Bathing: ICU
  • ICU (N=6): Daily Bathing Protocol

Six Months ‘Regular’, Six Months CHG

  • MRSA acquisition decreased 32% (p<.05)
  • VRE acquisition decreased 50% (p<.01)
  • VRE Bacteremia decreased (p=.02)

Crit Care Med 2008;37:185

chg bathing non icu
CHG Bathing: Non-ICU
  • N= 4 Hospital wards
    • 94 Beds; Rhode Island (>70K pt-days)
    • Daily CHG bathing (impregnated washcloth) vs. soap/water
  • Results:

Soap/WaterCHGP-value

N (pts) 7102 7699 ----

MRSA VRE HAIs 64% .01

Clostridium difficile…..no effect

ICHE 2011;32:238

chg bathing meta analysis
CHG Bathing : Meta-Analysis

N= 12 studies; 137,392 patient-days

Studies screened for methodolgic rigor

Results:

p-value

CRBSI/BSI reduction <.00001

Inf Ctrl Hosp Epid 2012;33:257

infection control and chg blueprint for success3
INFECTION CONTROL AND CHG: BLUEPRINT FOR SUCCESS

CENTRAL VENOUS CATHETERS

PERIPHERAL VENOUS CATHETERS

PATIENT BATHING PROTOCOLS

PREOPERATIVE PATIENT SHOWER

OPERATIVE TEAM HAND SCRUB

BLOOD CULTURE SKIN PREP

OPERATIVE SITE SKIN PREP

chlorhexidine preoperative showers
CHLORHEXIDINE: PREOPERATIVE SHOWERS

CDC recommends preoperative showering with CHG1

CHG more effective than PI & triclocarban

Lower rates of intraoperative wound contamination

1. Mangram AJ et al. The hospital infection control practices advisory committee. Guidelines for prevention of surgical site infection. Infect Control Hosp Epidemiol. 1999;20(4):250-278.

2. Garibaldi RA. Prevention of intraoperative wound contamination with chlorhexidine shower and scrub. J Hosp Infect. 1988;11(suppl B):5-9.

infection control and chg blueprint for success4
INFECTION CONTROL AND CHG: BLUEPRINT FOR SUCCESS

CENTRAL VENOUS CATHETERS

PERIPHERAL VENOUS CATHETERS

PATIENT BATHING PROTOCOLS

PREOPERATIVE PATIENT SHOWER

OPERATIVE TEAM HAND SCRUB

BLOOD CULTURE SKIN PREP

OPERATIVE SITE SKIN PREP

slide33
"History repeats itself;

that's one of the things

that's wrong with history."

Clarence Darrow

US Defense Lawyer

chg surgical scrub
CHG: SURGICAL SCRUB
  • CHG superior to povidone-iodine
    • Reduced hand bacterial counts at scrub
    • Reduction maintained 6 hours later

Orthopedics 2006:29:329

Surg Gynecol Obstet 1981;132:677

bacterial colony counts site prep
Bacterial Colony Counts/Site/Prep

2% CHG/70% IPA vs 0.7% Iodine 74% IPA; Hallux (P<0.01)

2% CHG/70% IPA vs 0.7% Iodine 74% IPA; Toe (P<0.05)

2% CHG/70% IPA vs 3% Chloroxylenol; Control (P<0.01)

Control = anterior tibia, 12 cm proximal to the ankle joint

Ostrander RV, et al. J Bone Joint Surg Am. 2005;87-A:980-985.

infection control and chg blueprint for success5
INFECTION CONTROL AND CHG: BLUEPRINT FOR SUCCESS

CENTRAL VENOUS CATHETERS

PERIPHERAL VENOUS CATHETERS

PATIENT BATHING PROTOCOLS

PREOPERATIVE PATIENT SHOWER

OPERATIVE TEAM HAND SCRUB

BLOOD CULTURE SKIN PREP

OPERATIVE SITE SKIN PREP

blood culture results truth or dare
Blood Culture Results: Truth or Dare

*Blood Culture Contamination (BCC):

Rate estimated at 0.6 - 6.0%

* Results in unnecessary Lab costs, hospital admissions, LOS, antibiotics

J Hosp Med 2006;1:272 Clin Microbiol Rev 2006;19:788

bcc efficacy of chg alcohol
BCC: Efficacy of CHG-Alcohol

P/Trial: ER (60% BC drawn in ER)

Compared Iodine vs. CHG-A skin prep

Results:

Iodine CHG-Alcohol p-value

BCC 3.5% 2.2% <.0001

J Nurse Care Qual 2008;23:272

blood culture contamination can it be reduced
Blood Culture Contamination: Can it be Reduced ?

Randomized/Crossover/Sterile Gloves

Results:

Routine Optional p-value

N 5265 5255 N/A

BCC,possible 0.6% 1.1% .009

BCC,likely 0.5% 0.9% .007

Ann Int Med 2011;154:145

blood cx contamination the newest bundle
Blood Cx Contamination: THE NEWEST BUNDLE?

Training in proper BC collection: Requirement for annual competency

? Time for a Blood Culture Bundle?

Ann Int Med 2011;154:202

infection control and chg blueprint for success6
INFECTION CONTROL AND CHG: BLUEPRINT FOR SUCCESS

CENTRAL VENOUS CATHETERS

PERIPHERAL VENOUS CATHETERS

PATIENT BATHING PROTOCOLS

PREOPERATIVE PATIENT SHOWER

OPERATIVE TEAM HAND SCRUB

BLOOD CULTURE SKIN PREP

OPERATIVE SITE SKIN PREP

ssi does choice of prep matter
SSI: DOES CHOICE OF PREP MATTER?

P/R trial comparing CHG-Alcohol (CA) and Povidine-Iodine (PI)

Clean-contaminated surgery (N = 849)

Pre-op prep, follow-up 30D post-op

Results

CAPIP-value

N 409 440

SSI (total) 9.5% 16.1% .004

Superficial 4.2% 8.6% .008

Deep 1% 3% .05

NEJM 2010;362:18

ssi does choice of prep matter1
SSI: DOES CHOICE OF PREP MATTER?

P/R trial comparing CHG-Alcohol and Povidine-Iodine

Clean-contaminated surgery (N = 849)

Pre-op prep, follow-up 30D post-op

Results (continued):

7 patients died (4 = CA; 3 = PI). None of CA deaths had SSI. All 3 PI deaths due to Sepsis from SSI.

NEJM 2010;362:18

chg alcohol c sections
CHG-Alcohol: C-Sections

2005: 4M live births in US annually

C-Sections account for 30% (>1M)

P/Trial (2006-2007): Pre-op CHGclothsandCHG-Aoperative prep

Results: Pre-Interv Interv p-value

SSI 7.5% 1.2% <.001

Projected cost savings: $25,546 per SSI

Am J Inf Control 2010;38:319

preoperative skin antisepsis chg vs iodine meta analysis
Preoperative Skin Antisepsis: CHG vs. Iodine : Meta-Analysis

Cost benefit decision analytic model

N=1508 screened: 9 met criteria

Summary: “Use of CHG for preoperative skin antisepsis is associated with a 36% reduction in the number of SSIs…Although CHG is more costly than Iodine, this dramatic reduction in the number of SSIs will likely result in greater overall cost savings with chlorhexidine use”

Am J Inf Control 2010;31:1219

ssi efficacy of chg a skin prep
SSI: Efficacy of CHG-A Skin Prep

…..In summary, the weight of evidence suggests that chlorhexidine alcohol should replace povidine-iodine as the standard for preoperative surgical scrubs.

NEJM 2010;362:1

infection prevention four pillars2
INFECTION PREVENTION: (FOUR) PILLARS

*De-populate the patient

*De-populate the space

*De-instrument the patient

*De-escalate the ABX

fole

environmental contamination vre
ENVIRONMENTAL CONTAMINATION: VRE

VRE persists through an average of 2.8 standard room cleanings

ICHE 1998;19:261

environmental cleaning mdr control
ENVIRONMENTAL CLEANING: MDR CONTROL?

Purpose

To assess the efficacy of environmental cleaning protocols for reduction of VRE, C. difficile

Baseline Post-Routine Post-Bleach

 CxCleaningCleaning

VRE (N = 17) 94% 71% 0

(p < .001)

C. diff (N = 9) 100% 78% 11%

(p = .03)

. . . Implications . . .

BMC Inf Dis 2007;7:61

environmental contamination vre1
ENVIRONMENTAL CONTAMINATION: VRE

14 month study; N = 1330 ICU admissions

Weekly environmental Cx

Twice weekly pt Cx

8% at-risk patients acquired VRE

Risk factors for VRE acquisition

Prior VRE  occupant (p = .007)

Prior VRE  environmental Cx (p < .001)

CID 2008;46:678

infection prevention four pillars3
INFECTION PREVENTION: (FOUR) PILLARS

*De-populate the patient

*De-populate the space

*De-instrument the patient

*De-escalate the ABX

fole

ca uti nurse led model
CA-UTI: NURSE-LED MODEL
  • Urinary catheters (UC) vs unnecessary urinary catheters (UUC)
  • 2006-2007; 10 hospital units (N=4,963 PD)
    • 18% UC days
  • Results: UC UUC

(per 1000 PD)P-value(per 1000 PD)P-value

Pre-interv. 203 102

.002.001

Intervention 162 64

.05.01

Post-interv. 187 91

ICHE 2008;29:815

ICHE 2008:29:820

infection prevention four pillars4
INFECTION PREVENTION: (FOUR) PILLARS

*De-populate the patient

*De-populate the space

*De-instrument the patient

*De-escalate the ABX

fole

antibiotic stewardship issues
Antibiotic Stewardship Issues
  • Empiric ABX Order Set:

Computer Physician Order Entry (CPOE)

CID 2007; 44: 159

  • VAP De-escalation (8 Days of ABX)

JAMA 2003;290:2588

  • Bacteremia vs. Fungemia (example)
  • CAUTI: CID 2010;50:625
  • Institutional Antibiogram
infection prevention four pillars5
INFECTION PREVENTION: (FOUR) PILLARS

*De-populate the patient

*De-populate the space

*De-instrument the patient

*De-escalate the ABX

fole

infection control in the modern era blueprint for success
INFECTION CONTROL IN THE MODERN ERA: BLUEPRINT FOR SUCCESS

MDRO case finding = ASC isolation

CHG10% bleach

 Colonization   Infection   Death

De-instrument  ABX pressure De-escalate

the patientthe ABX

 MDRO

?  LOS/? Improved antibiogram