effective strategies to resistance: why hand itt ... · 1 effective strategies to reduce hais and...

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Effective strategies to reduce HAIs and antimicrobial resistance: Why hand hygiene is an i t t t

Anthony Harris MD, MPH

important component ProfessorActing Medical Director of Infection ControlHead Division of Genomic Epidemiology and Clinical OutcomesUniversity of Maryland School of Medicine

Outline of talk

Discussion of important healthcareDiscussion of important healthcare-associated infection (HAIs)Science of how to decrease HAIsEpidemiological issues of HAIs researchWhy hand hygiene is importantWhy hand hygiene is important

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Outline of talk

Discussion of important healthcareDiscussion of important healthcare-associated infection (HAIs)Science of how to decrease HAIsEpidemiological issues of HAI researchWhy hand hygiene is importantWhy hand hygiene is important

HAIsHAIsCentral-line associated bacteremiasVentilator-associated pneumoniaSurgical-site infectionCatheter-associated urinary tract infection

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Importance of HAIs

1 of every 10-201 of every 10-20 patients hospitalized in the United States develops a healthcare-associated infection

Importance of HAIs

The US Centers for Disease Control andThe US Centers for Disease Control and Prevention estimates that nearly 2 million patients (5%-10% of hospitalized patients) experience an HAI each yearThese infections lead to almost 100,000 deaths and $28-$33 billion in extra costs.

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Cost of HAIsInfection type Attributable

costsExcess length of stay

Ventilator- $22,875 9.6 (7.4-11.5)Ventilatorassociated pneumonia

$22,875 ($9,986-$54,503)

9.6 (7.4 11.5)

CLABSI $18,432 ($3,592-$34,410)

12 (4.5-19.6)

)Catheter-associated urinary tract infection

$1,257 ($804-$1,710)

Eber MR, Arch Intern Med. 2010;170:347

Outline of talk


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a a osp taepidemiologist, infection preventionist, or hospital administrator with an HAI problem what literature should I look

t th t h h tat that shows what interventions may work?

SHEA guidelinesSHEA guidelinesCenters for Disease Control and PreventionHICPAC guidelinesIDSAAPICHHS

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SHEA guidelines

To assist acute care hospitals in focusing andTo assist acute care hospitals in focusing and prioritizing efforts to implement evidence-based practices for prevention of HAIs, the Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America Standards and Practice Guidelines Committee appointed a task force to create a concise compendium of recommendations for the prevention of common HAIs

http://www.shea-online.org/about/compendium.cfm

CLBSI

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CLABSI: Effective interventions

At insertionAt insertionUse a catheter checklist to ensure adherence to infection prevention practices at the time of central venous catheter insertionPerform hand hygiene before catheter insertion or manipulationAvoid the femoral veinAvoid the femoral veinUse an all-inclusive catheter cart or kitUse maximal sterile barrier precautions during central venous catheter insertionUse a chlorhexidine-based antiseptic for skin preparation

CLABSI: Effective interventions

After insertionAfter insertionDisinfect catheter hubs, needleless connectors, and injection ports before accessing the catheter Remove nonessential catheterse o e o esse a ca e e s

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Effective interventions in difficult situations

Bathe ICU patients with a chlorhexidineBathe ICU patients with a chlorhexidine preparation on a daily basisUse antimicrobial-impregnated central venous cathetersUse chlorhexidine-containing sponge Use c o e d e co a g spo gedressings for central venous cathetersUse antimicrobial locks for central venous catheters

VAP: Effective interventions

Implement policies and practices for disinfectionImplement policies and practices for disinfection, sterilization, and maintenance of respiratory equipmentEnsure that all patients are maintained in a semi-recumbent positionPerform regular antiseptic oral care inPerform regular antiseptic oral care in accordance with product guidelinesProvide easy access to noninvasive ventilation equipment and use weaning protocols

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UTI: Effective interventions

Provide and implement written guidelines forProvide and implement written guidelines for catheter use, insertion, and maintenanceEnsure that only trained personnel insert urinary cathetersEnsure that supplies necessary for aseptic-technique catheter insertion are availableImplement a system for documenting: indications for catheter insertion, date and time of catheter insertion, individual who inserted catheter, and date and time of catheter removal

SSI: Effective interventions

Administer antimicrobial prophylaxisAdminister antimicrobial prophylaxis Do not remove hair at the operative site unless the presence of hair will interfere with the operationDo not use razorsControl blood glucose level during the immediate postoperative period for patientsimmediate postoperative period for patients undergoing cardiac surgeryMeasure and provide feedback to providers on the rates of compliance with the above process measures

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Outline of talk


Epidemiological barriers

Too few randomized clinical trialsToo few randomized clinical trials Few to no cluster randomized trials in infection controlSub-optimal quasi experimental studies

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Q: What is a quasi experimental study?

Definition

Q: What is a quasi-experimental study?

A: Study that aims to evaluate interventions but does not utilize a randomized control group a do ed co o g oup

Overview of Clinical Research

From Grimes and Schultz. Lancet. 2002;359:57-61

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Textbooks

Shadish et al. Experimental and Quasi-experimental Designs. Houghton Mifflin Co; 2001.Cook and Campbell. Quasi-experimentation: Design and Analysis Issues for Field Settings. Houghton Mifflin Co; 1979.

(A) Quasi-experimental designs without

Types of QE Studies( ) p gcontrol groups(B) Quasi-experimental designs that use control groups but no pretest(C) Quasi-experimental designs that use control groups and pretestsuse control groups and pretests(D) Interrupted time-series designs

Harris AD. The use and interpretation of quasi-experimental studies in infectious diseases. Clin Infect Dis. 38:1586-91. 2004

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A. Quasi-experimental designs without control groups

Hierarchy of QE Designs

2. The one-group pretest-posttest design:O1 X O2

3. The one-group pretest-posttest design using a double pretest:O1 O2 X O3

4. The one-group pretest-posttest design using a nonequivalent dependent variable: (O1a, O1b) X (O2a, O2b)

5. The removed-treatment design:O1 X O2 O3 removeX O4

6. The repeated-treatment design:O1 X O2 removeX O3 X O4

O = observational measurement; X = intervention under study.Time moves from left to right.

Systematic Review ID Literature (cont)

73 articles used quasi-experimental designs in infection /

q p gcontrol and/or antibiotic resistance studies in 4 journals over a 2 year period

Few studies used higher-level quasi-experimental design

Only 16% used a control group

Harris et al. Clin Infect Dis. 2005;41:77-82.

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Future Quasi-experimental Studies Should Include…

Use of standard nomenclatureUse of standard nomenclatureChoice of “higher level” studies if possible

Add control group, multiple measurements

Discussion of why the specific study design and analysis was chosenyDiscussion of particular study limitationsCollaboration with statisticians to improve analysis

Stone SP, The Orion Statement J Antimicrob Chemother. 2007 May;59:833

Outline of talk

Discussion of important healthcareDiscussion of important healthcare-associated infection (HAIs)Science of how to decrease HAISEpidemiological issues of HAI researchWhy hand hygiene is importantWhy hand hygiene is important

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Hand hygiene

Cornerstone of infection controlCornerstone of infection controlPrevents the transmission of both susceptible and resistant bacteria

P i i fPrevent cross transmission of microorganisms

from patient-to-patient

from body site to body site on the patient

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What is the relative importance of infection control versus antibiotic use in driving antibiotic resistance?

If I knew this I would be a genius and a millionaire.

Risk Factors for Antibiotic-Resistant Infections

Hospital-level FactorsHand washing CrowdingNurse-Patient Ratios Glove gown and mask use

Patients uninfectedPatients infected by

tibi ti i t t

Nurse-Patient Ratios Glove, gown, and mask useColonization pressure Cleanliness of surroundings

Patients uninfected by antibiotic resistant

bacteria

antibiotic resistant bacteria

Individual-level FactorsAntibiotic use Immune systemSeverity of illness AgeComorbid conditions

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Transmissibility compared to other organisms

HCW Gown

Organism

HCW Room Entrie

s

Hand + Before

(%)

Gown and/or

Glove + After %

Hands + After

RemovalA.

baumannii 199 1.7% 38.7% 4.5%

P. aeruginosa 133 0% 8.2% 0.8%aeruginosa

VRE# 94 0% 9% 0%

MRSA# 81 2% 19% 2.6%

# Snyder G, et al, Infect Control Hosp Epidemiol July 2008; 29:584 and Morgan D, et al, Infect Control Hosp Epidemiol. June 2010;31:716

After Contact with Patients Infected/Colonized with …

MDR Acinetobacter baumannii… MDR Acinetobacter baumannii

40% of Gloves/Gowns were Contaminated 4% of Hands were Contaminated after removal of gloves

… MRSA

18.5% of Gloves/Gowns1% of Hands Contaminated

… VRE

8.5% of Gloves/GownsNo Hands Contaminated

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Adult hospitals p

Unit Complianc

e Reference

ICUs 41% NEJM 1981;304:1465-1466

Ward/ICU

32% AM J Infect Control 1989;17:330-339

Ward/ICU

21% Hosp Infect Control 1989;16:100-101

ICU 30-48% NEJM 1992;327:88-93

SICU 38% Am J Infect Control 1994;22:228-3001994;22:228-300

all ICUs 32% Ann Emerg Med 1994;23:1307 1312

ICU 36% Ann Intern Med 1999. 130:126-130.

Ward/ICU

48% Ann Intern Med 1999. 130:126-130.

In the day to day world certain issuesIn the day-to-day world certain issues arise:

How do you sustain an intervention?How do you get ground-level buy in?How do you deal with the powerful naysayers?What logistical issues arise?How do you stay on top of all the logistical issues?

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Illustrative example: Hand Hygiene

Literature has consistently shown handLiterature has consistently shown hand hygiene levels to be below 60%Numerous interventions work but only temporarilyYet, JCAHO during their audits aims for e , JC O du g e aud s a s o100% levels

“Stephan your hospital has the mostStephan, your hospital has the most sophisticated and expensive hand hygiene campaign in in the world. What are your hand hygiene compliance rates?” - Bill Jarvis, MD“About 60-70%” - Stephan Harbarth MD MS, Geneva

Society for Healthcare Epidemiology of America, San Diego, CA. March 22, 2009

FOR MORE INFO...

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Alcohol handrubs (in conjunction with hospital wide campaign to increasehospital-wide campaign to increase compliance)

Improved compliance (48% to 66%)Decreased

Pittet, Lancet, October 2000

ec easedMRSA incidence (2.16 to 0.93 episodes per 10,000 patient days) overall nosocomial infections (17% to 10%)

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Lancet 2000; 356: 1307-12

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Randomly assigned squatter settlementsRandomly assigned squatter settlements in Karachi Pakistan, 1 year follow-up

25 Communities Handwashing Promotion300 households – triclocarban antibacterial soap300 households – plain soap

*Luby SB et al. Lancet 2005;366:225-233.

11 Community Controls (300 households)Pneumonia reduced 50%, diarrhea reduced 53% and impetigo reduced 34% in childrenNo benefit of antibacterial soap over plain soap

Systematic ReviewSystematic ReviewThings that don’t work

One off educationAutomated sinksNew soaps

Naikoba S and Hayward A. J Hosp Infect 2001

Things that do workRole modelsSelf protectionMulti-facted education, written material and sustained feedback

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Annotated bibliography

Naikoba S et al The effectiveness ofNaikoba S et. al, The effectiveness of interventions aimed at increasing handwashing in healthcare workers - a systematic review. J Hosp Infect. 2001;47:173. “Very nice article but a little ld”old”.

Conclusions

HAIs can be reducedHAIs can be reducedLevel of science needs to be improved to determine which interventions are optimalMaintenance and sustainability of successful interventions is a difficult success u e e o s s a d cuprocess

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Gould DJ et. al, Interventions to improve hand hygieneGould DJ et. al, Interventions to improve hand hygiene compliance. Cochrane Database Syst Rev. 2010;(9):CD005186. “Cochrane review of hand hygiene interventions.”Bolon M et. al, Hand hygiene. Infect Dis Clin North Am. 2011;25:21. “Recent review of hand hygiene”. Pitet D et. al, Effectiveness of a hospital-wide

t i li ith h d h iprogramme to improve compliance with hand hygiene. Infection Control Programme. Lancet 2000; 356: 1307-12. “One of the better hand hygiene intervention studies.”


Marra AR et al Positive deviance: AMarra AR, et. al, Positive deviance: A program for sustained improvement in hand hygiene compliance. Am J Infect Control 2011;39:1-5. “Article addressing improved hand hygiene with positive d i h i ”deviance technique.”

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Eber MR et al Clinical and economicEber MR et. al, Clinical and economic outcomes attributable to health care-associated sepsis and pneumonia. Arch Intern Med. 2010;170:347. http://www.shea-online org/about/compendium cfm SHEAonline.org/about/compendium.cfm SHEA compendium guidelines of reducing HAI infections


Harris AD et al The use andHarris AD et. al, The use and interpretation of quasi-experimental studies in infectious diseases. Clin Infect Dis. 2004. 38:1586. “One of a series of articles outlining how to perform quasi-

i l di ”experimental studies”

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