Health care precautions dealing multidrug resistant infected patients

1. Health care precautions dealing multidrug resistant infected patients Dr.T.V.Rao MD Dr.T.V.Rao MD

2. Multidrug-Resistant Organisms (MDROs) • MDROs are defined as microorganisms – predominantly bacteria – that are resistant to one or more classes of antimicrobial agents. Although the names of certain MDROs suggest resistance to only one agent (e.g., methicillin-resistant Staphylococcus aureus [MRSA], vancomycin resistant enterococcus [VRE]), Extended spectrum Betalactamse, carbapenemases resistant bacteria, these pathogens are usually resistant to all but a few available antimicrobial agents. Dr.T.V.Rao MD

3. Important MRDO,s in hospital practice • Streptococcus pneumonia (MDRSP) which is resistant to penicillin and other broad-spectrum agents such as macrolides and fluoroquinolones, multidrug-resistant gram-negative bacilli (MDR- GNB), especially those producing extended spectrum beta-lactamases (ESBLs); and strains of S. aureus that are intermediate or resistant to vancomycin (i.e., VISA and VRSA) Dr.T.V.Rao MD

4. Why multidrug resistant bacteria are important MDROs that are considered to be epidemiologically important and deserve special attention in healthcare facilities Dr.T.V.Rao MD

5. Transmission of mdro’s • MDROs are transmitted by the same routes as antimicrobial susceptible infectious agents. Patient-to-patient transmission in healthcare settings, usually via hands of HCWs, has been a major factor accounting for the increase in MDRO incidence and prevalence, especially for MRSA and VRE in acute care facilities Dr.T.V.Rao MD

6. Patient Isolation Precautions for Hospitals- • Multidrug-resistant organisms (MDRO’s)may require more stringent protection, such as methicillin resistant Staphylococcus aureus (MRSA).ESBL ( Extended spectrum Beta lactamases, Multidrug drug resistant bacteria and Pan resistant bacterial pathogens Dr.T.V.Rao MD

7. Standard Precautions (Basic level) Are used for care of ALL patients in a hospital all of the time regardless of diagnosis or infection status Combine the major features of universal, and body substance precautions, terms formerly used Applied to blood, body fluids, excretions and secretions regardless of whether they contain visible blood, mucous membranes and non-intact skin All other transmission-based precautions include (are in addition to) Standard Precautions Level of use depends on anticipated contact with patient Patient Isolation Precautions for Hospitals- Dr.T.V.Rao MD

8. Isolation Precautions Hand hygiene Patient placement PPE Isolation Precautions Patient Transport Decontamination Linen & laundry Waste Management Dr.T.V.Rao MD

9. Other Transmission-Based Precautions Commonly Used in Hospitals Consist of: Direct and Indirect Contact Precautions Airborne Precautions Droplet Precautions These may be used in combinations depending on whether the microorganisms and infection in question have multiple routes of transmission with barrier nursing. Special adaptations may be needed for multidrug resistant organisms and Category A agents of bioterrorism. Patient Isolation Precautions for Hospitals- Dr.T.V.Rao MD

10. Nursing education is most important tool in controlling infection • Unit staff should be educated and updated frequently as to appropriate infection control for patients on their unit. • If possible, dedicate same patient care staff to care of infected patient(s) during their stay. Dr.T.V.Rao MD

11. General Measures • The general hospital environment and "permanent" equipment need to be protected • Appropriate sharp/needle precautions should be followed as should proper disposal of clinical waste and laundry Dr.T.V.Rao MD

12. Hand hygiene after patient contact Wear clean, non-sterile protective gloves when touching blood, body fluids, secretions, excretions and contaminated items Wear mask, eye protection or facial shield and gown during procedures likely to generate splashes or spray of blood, body fluids, secretions or excretions. Use depends on anticipated exposure and safe injection practices as well Patient Isolation PrecautionsStandard Precautions Dr.T.V.Rao MD

13. Intended to prevent spread of microorganisms from an infected patient through direct means (touching the patient) and indirect means (touching surfaces or objects that have been in contact with the patient). These objects include chairs, bedrails, telephones, IV pumps, light switches and so on. Placing the patient in a private room is preferred or when not available, it is recommended that a set of principles be followed such as cohorting with someone with the same infection. Contact PrecautionsConsists of standard precautions Dr.T.V.Rao MD

14. Extended standard precautions • Three new elements have been added to standard precautions. These are: • Respiratory hygiene/cough etiquette • Safe injection practices • Use of masks for insertion of catheters or injection into spinal or epidural areas Dr.T.V.Rao MD

15. Contact Precautions • Leak resistant bag for linens should be at bedside. • Dedicated thermometer, B/P apparatus and stethoscopes are preferred unless unavoidable and then must be cleaned and completely disinfected before using with other patient. • Indirect contact transmission can occur when a susceptible patient is in contact with an intermediate inanimate object in the patient’s environment. Dr.T.V.Rao MD

16. Handwashing and Hand Hygiene One of the most important ways to protect against transmission of microbes and disease is hand hygiene Dr.T.V.Rao MD

17. Perform hand hygiene: Before and after patient contact After removing gloves or any other PPE item After touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn After contact with patient surroundings Routine hand hygiene by alcohol hand rub (preferably) or by washing hands with soap and water Perform hand hygiene after touching surgical mask/ N 95 respirator or before touching the face Hand hygiene Dr.T.V.Rao MD

18. When expose to blood, body fluids, secretions, excretions, mucous membranes and non-intact skin, and contaminated items Perform hand hygiene immediately after glove removal dealing with used Gloves • Change gloves when heavily contaminated 4. Disposable glove should not be reused

19. EPA-registered disinfectants or detergents/disinfectants • EPA-registered disinfectants or detergents/disinfectants that best meet the overall needs of the healthcare facility for routine cleaning and disinfection should be selected . In general, use of the existing facility detergent/disinfectant according to the manufacturer’s recommendations for amount, dilution, and contact time is sufficient to remove pathogens from surfaces of rooms where colonized or infected individuals were housed. This includes those pathogens that are resistant to multiple classes of antimicrobial agents (e.g., C. difficile, • VRE, MRSA, MDR-GNB Dr.T.V.Rao MD

20. Common Cleaners from EPA list: • 1. Lysol Brand Deodorizing Disinfectant Cleaner • 2. Lysol Brand Pre-Moistened Touch-Ups Disinfecting Cleaning Wipes • 3. Lysol Brand Disinfectant Direct Multi-Purpose Cleaner • 4. Mr. Clean Multi-Surfaces Antibacterial • 5. Ultra Clorox Brand Regular Bleach • 6. Clorox Disinfecting Spray III • 7. Hydrogen Peroxide • 8. Pine Oil • 9. Bio Clean • 10.Ready-To-Use Bathroom Cleaner and Disinfectant Dr.T.V.Rao MD

21. Should be done: Before gloving, After removing gloves After touching blood, body fluids, tissues, secretions, excretions or any contaminated items. If not visibly soiled can use alcohol- based but if visibly soiled or contaminated with proteinacious material use soap and wash hands. Between patients After procedures on some patients to prevent cross-contamination of different body sites After contact with patients intact skin or inanimate objects near the patient Handwashing and Hand Hygiene- Dr.T.V.Rao MD

22. Wash with soap and water at least 15 seconds when hands are visibly soiled and follow institutional procedures Use friction Can use alcohol-based rubs to decontaminate hand, if soiled Fingernails should be short, clean and free from polish Artificial nails should be avoided Hand washing and Hand Hygiene- Dr.T.V.Rao MD

23. Rings should not be worn Watches and bracelets should be removed For alcohol-based rubs, apply to palm of one hand and rub hand together covering all surfaces of hand and fingers until hands are dry Paper towels should be used to dry hands. Do not touch faucet handles with hands after washing Hand washing and Hand Hygiene- Dr.T.V.Rao MD

24. If patient has airborne or droplet transmitted infection should only leave room, if essential Patient should wear mask during transport Transport personnel should wear appropriate PPE Transport route should avoid populated areas Receiving personnel should be aware of what PPE and infection control procedures are needed and when patient is coming Protect stretchers or wheelchairs appropriately Appropriate hand hygiene should be used Infected Patient Transport Within Institution Dr.T.V.Rao MD

25. Transport of Suspected or confirmed patient • Limit patient transport unless clinically indicated • Encourage patients to wear surgical mask if no contraindication • Inform the receiving service/department of concern beforehand • Clean / disinfect transport vehicles after use

26. Infected Patient Transport Within Institution- • Disinfect all transport equipment and linens • Patient should be in clean gown • Patient should wear or use appropriate barriers such as impermeable dressings for wounds • Let patients know how they can assist Dr.T.V.Rao MD

27. Dedicated non-critical patient care items for suspected and confirmed cases Clean and disinfect reusable equipment before used on other patients. Use 1,000 ppm of hypochlorite solution (i.e. add 1 part of 5.25% hypochlorite in 49 parts of water) to disinfect non-critical items Use 70% alcohol on metallic surfaces Reusable respiratory equipment should undergo high level disinfection before reused on other patients Decontamination - Patient Care Items

28. Decontamination - Environmental Control Disinfect isolation and procedure rooms after use by a high risk patient • Clean and disinfect the environment regularly and additional session for frequently touched surfaces • Contaminated area should be disinfected by one part of hypochlorite solution add in 49 parts of water • If blood spills occur: • Use one part of hypochlorite solution add in 49 parts of water for non-metallic and 70% alcohol for metallic items. • If spills involve large amount of blood, the blood should be removed by disposable material soaked with one part of hypochlorite solution add in 4 parts of water before further cleaning and disinfection Dr.T.V.Rao MD

29. Instruction should include cont.: Offering masks to persons who are coughing, Separating coughing persons at least 3 feet away from others in a waiting room or have separate locality. Instructing patients and providers not to touch eyes, nose, or mouth. Having health care personnel observe droplet precautions in addition to standard precautions. Health care workers should use standard precautions with all patients. Patient Teaching/Cough Etiquette- Dr.T.V.Rao MD

30. Limit unnecessary procedures Limit extent of procedure Limit number of persons involved Effective decontamination of used items Principles of precautions for high-risk procedures in MDRo’S

31. Practice rationalism of antibiotic usage • Judicious antibiotic use, comprehensive surveillance for targeted MDROs, application of infection control precautions during patient care, environmental measures (e.g., cleaning and disinfection of the patient care environment and equipment, dedicated single-patient-use of non-critical equipment), and decolonization therapy when appropriate. Dr.T.V.Rao MD

32. Prevention and transmission is a complex problem • Preventing the emergence and transmission of these pathogens requires a comprehensive approach that includes administrative involvement and measures (e.g., nurse staffing, communication systems, performance improvement processes to ensure adherence to recommended infection control measures), education and training of medical and other healthcare personnel, Dr.T.V.Rao MD

33. Control of mdro’s is a national priority • The prevention and control of MDROs is a national priority - one that requires that all healthcare facilities and agencies assume responsibility and participate in community-wide control programs Dr.T.V.Rao MD

34. Multidrug resistant strains are a global problem we are all concerned • Antibiotic resistance has both medical and financial costs. It causes longer and more serious illnesses, lengthening people’s stays in hospital and complicating their treatment. Sometimes people die unnecessarily. . At the moment, resistant bacteria threaten mostly children, the old, cancer patients and the chronically ill. Nearly 450,000 new cases of multidrug-resistant tuberculosis are recorded each year; one-third of these people die from the disease. More than a quarter of new cases of TB identified recently in parts of Russia were of this troublesome kind. Dr.T.V.Rao MD

35. Programme created by Dr.T.V.Rao MD for Medical and Health care Workers in the Developing World • Email • doctortvrao@gmail.com Dr.T.V.Rao MD