top10 ic freiburg

05-‐10-‐15

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Prof. Dr. Andreas Voss Radboud umc

Canisisus-‐Wilhelmina Hospital Nijmegen, The Netherlands

¤  Hand hygiene

¤  Environment & machines/scopes

¤  FighKng MDROs

¤  Skin disinfecKon/decolonizaKon

¤  SSI & OperaKng Room

… oder besser !

JAMA Intern Med. doi:10.1001/jamainternmed.2014.6781 Published online December 22, 2014

InfecKon control talks are generally rated as “therapeuKc” for HCWs with sleeping disorders.

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¤  35 hospitals, 56 nursing homes ¤  >4000 HCWs from 56 nursing units ¤  13.8 million HH opportuniKes captured via RFRD

¤  HH compliance ²  Start of shi_: 42.6% ²  End of shi_: 34.8%

Dia et al. J Appl Psychol 2014

Isaacson et al. AJIC 2015:43;530

¤  14 HCWs ¤  Nontoxogenic spores of C. difficile pipebed onto hands

¤  6-‐study arms in random order


No hand washing

Medicated soap


Water alone rubbing & rising

Water alone rising only

Rubing with sand than rising

Rubing with baking soda and oil, than dish-‐detergent, than rising

1.98 2.34 1.90

1.84 2.21


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Harris et al. JAMA 2013;310:1571

¤  Cluster-‐randomized trial in 20 medical and surgical ICUs in 20 US hospitals.

¤  IntervenKon = Universal gloves & gown use versus gloves & gown for known MRSA and VRE paKents

¤  Primary outcome was acquisiKon of MRSA or VRE based on surveillance cultures collected on admission and discharge from the ICU.


¤  The use of gloves and gowns for all paKent contact compared with usual care among paKents in medical and surgical ICUs did not result in a difference in the primary outcome of acquisiKon of MRSA or VRE

¤  No difference in individual VRE-‐acquisiKon

¤  Less individual MRSA-‐acquisiKon


environment

hands

¤  Compliance with gloves & gowns was about 85% in intervenKon group, 80% in control

¤  HH compliance 56% vs 51% (intervenKon versus control group)

¤  Is it even possible to show a difference with regard to one IC measure in a high prevalence semng?


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¤  Highest transfer of bacteria: handshake

¤  Lowest transfer of bacteria: fist bump

(high five was in the middle)

¤  ExplanaKon: handshakes have the greatest surface area in contact, for a longer Kme

Mela et al. Am J Infect Control 2014;42:916-‐7

Yoh doc ¤  Hand hygiene


¤  FighKng MDROs


¤  SSI

Vandini et al PLoS ONE 2014; 9: e108598. doi:10.1371/journal.pone.0108598

Bacillus

subDlis,

Bacillus

pumilus

and Bac

illus me

gaterium

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Vandini et al PLoS ONE 2014; 9: e108598. doi:10.1371/journal.pone.0108598

Microbial-‐based cleaning started

ConvenKonal cleaning started

E.coli

S. aureus

… but (methods)

Thom et al. Infect Control Hosp Epidemiol 2014;35:1060-‐62


¤  MSDS Poly spray (silicone quaternary amine)

¤  8 surfaces

²  sink, call bubon, bedside table, monitor, telephone, supply cart, door handle, floor

¤  Results:

² No significant effect on environmental contaminaKon


¤  Problem adherence?

¤  Love the concept of changing the surface

¤  Studies with copper, silver silica, Biosafe HM 4100 (polymer) embedded in polyurethane, light-‐acKvated anKmicrobials, … have worked before

Freeman et al. AnKmicrob Resistance Infect Control 2014;3:5

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¤  We systemaKcally sampled 8 surfaces in the rooms and bathrooms of adult paKents colonized or infected with ESBL-‐EC or ESBL-‐KP throughout their hospital stay.

¤  Environmental contaminaKon was defined as recovery of an ESBL-‐producing organism matching the source paKent’s isolate

Freeman et al. AnKmicrobial Resistance and InfecKon Control 2014, 3:5

¤ 



Rooms of paKents with ESBL-‐KP have substanKally higher contaminaKon rates than those with ESBL-‐EC. This finding may help explain the apparently higher transmissibility of ESBL-‐KP in the hospital semng

Kampf et al. BMC Infect Dis 2014;14:37

Kampf et al. BMC Infect Dis 2014;14:37

¤ Reusable Kssue dispensers with different surface disinfectants were randomly collected from healthcare faciliKes.

¤ 66 dispensers containing disinfectant soluKons with surface-‐acKve ingredients were collected in 15 healthcare faciliKes. 28 dispensers from nine healthcare faciliKes were contaminated

¤ In none of the hospitals dispenser processing had been adequately performed

… it is not about the details of this paper, but the point that even

“helpful parts of the environment” may be a source for infecKons

¤  NIH program to encourage handwashing in hospitals and day care centers

¤  Program promotes a symbolic teddy bear (T. Bear) with slogans/reminders to pracKce HH.

¤  Stuffed T. Bear was dispensed to the hospitalized child.

¤  Could T. Bear serve as a "fomite”?

Hughes et al. Infect Control. 1986 Oct;7(10):495-‐500

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¤ ProspecKve study of 39 sterilized T. Bears, one week a_er use: ² S.aureus, K.pneumoniae, P.aeruginosa, E.coli, Candida spp, Cryptococcus, Aspergillus and others.

² Although the T. Bear handwashing campaign should not be discredited, the promoKonal toy may pose an unnecessary expense and hazard and should not be used in hospitals.

Hughes et al. Infect Control. 1986 Oct;7(10):495-‐500

110 paKent encounters

Ama et al. Infect Control Hosp Epidemiol 2013;34:1331

18 40 28 23

Ama et al. Infect Control Hosp Epidemiol 2013;34:1331

Cleaning of equipement 14% before and a_er use

PaKent in contact isolaKon 24%

PaKent not in contact isol. 7%

LongKn et al. Mayo Clin Proc 2014;89:291-‐299

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Sax et al. Clin Infect Dis April 15, 2015 Sax et al. Clin Infect Dis April 15, 2015 Sax et al. Clin Infect Dis April 15, 2015 First 6 cases

Sax et al. Clin Infect Dis April 15, 2015

Takes years to develop

Aerogenic spread

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¤  NDM1-‐producing E. coli in 2013 ¤  Case-‐Control Study

²  ERCP procedure: OR 78 ²  AnKbioKcs: OR 9

¤  Cohort Study ²  mulKple endoscope exposures (71%) more likely to have NDM1-‐producing E. coli. Single exposure – 41%.

Eppstein et al. JAMA 2014;312

¤  Clonal outbreak of 22 paKents with VIM-‐ posiKeve P. aeruginosas

¤  Common denomintor: ERCP (Olympus Q180) ¤  DestrucKve cultures of scope – idenKcal micro-‐ organism under “elevator”

¤  A_er excluding scope from use – no further cases

Verfaille et al. Endoscopy 2015;47:493

¤ A. fumigatus in reverse osmosis unit supplying 10 endoscope re-‐processors with water for final rinse

¤ MulKple abempts to disinfect machines, basins and water purificaKon system failed

Khalsa et al. Am J Infect Control 2014;1-‐3

Only replacement of all filters and RO membrane solved the problem: “breakthrough

growth”

¤  Hand hygiene


¤  FighKng MDROs


¤  SSI

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hbp://www.cddep.org

hbp://www.cddep.org

Bibe selber lesen – jetzt keine Zeit

PLOS ONE | DOI:10.1371/journal.pone.0116746 March 18, 2015



… poor governance and corrupKon contributes to levels of anKbioKc resistance and correlate beber than anKbioKc

usage volumes with resistance rates

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Gastmeier et al. JAC 2014;6:1660 Gastmeier et al. JAC 2014;6:1660

Data from German naKonal nosocomial surveillance system (KISS)

Gastmeier et al. JAC 2014;6:1660

SSI

UTI

BSI

Gastmeier et al. JAC 2014;6:1660

The high overall VRE proporKon in Germany is mainly due to the situaKon in four states (Rhine-‐Westphalia, Hesse, Thuringia and Saxony ). There is an urgent need to analyse the

epidemiology of VRE in detail to develop appropriate infecKon control strategies

Jurke et al. Euro Surveill. 2013;18(36):pii=20579

¤ In 2007, all hospitals started to systemaKcally screen defined paKents associated with any one of the known risk factors, prior to or upon admission to a hospital.

¤ From 2007 to 2011, the MRSA admission incidence (0.51 vs 1.09 MRSA cases/100 paKents admibed), the MRSA incidence density (0.87 vs 1.54 MRSA cases/1,000 paKent days) as well as the mean daily MRSA-‐burden (1.30 vs 1.82 MRSA-‐in-‐hospital days/100 paKent days) increased significantly (p<0.0001)


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MRSA Screenings Paradox = Wer sucht – der findet !

Fätkenheuer et al Lancet 2014, published online Aug 21st

Fätkenheuer et al Lancet 2014, published online Aug 21st Fätkenheuer et al Lancet 2014, published online Aug 21st

Hand hygiene +++ Screening ? Isolation Decolonization +

“the strategy of screening and isolaFon cannot be regarded as a gold standard

to prevent the spread of MRSA”

… okay, but what did we do in the NL –

screen & isolate and 20% HH compliance

Hetem et al. Emerging Infect Dis 2013;19:1797

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Hetem et al. Emerging Infect Dis 2013;19:1797

Transmissibility of LA-‐MRSA is (sKll) 4.4 Kmes lower than that of other MRSA

(not associated with livestock)

IN THE MRSA EPIDEMIOLOGY

¤  sequence type (ST) 8 community-‐associated geneKc lineage, SCCmec type IVa, spa type t292 related to MRSA lineage USA300

Rossi et al. NEJM 2014,370:1524 Rossi et al. NEJM 2014,370:1524

IN THE MRSA EPIDEMIOLOGY

Hearing CA-MRSA USA300 & vanco-resistance in one

strain gives me the creeps …

¤  Hand hygiene


¤  FighKng MDROs


¤  SSI

Maiwald & Chan J AnKmicrob Chemother 2014;69:2017

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Maiwald & Chan J AnKmicrob Chemother 2014;69:2017

chlorhexidine

alcohol

Povidone-‐iodine

Charehbili Surg Infect 2014;15:DOI: 10.1089/sur.2012.185

¤  Single center, non-‐randomized, non-‐blinded, retrospecKve study

¤  2010 and prior: 1% iodine in 70% alcohol

¤  2011 and a_er a preparaKon of 0.5% chlorhexidine in 70% alcohol

¤  SSI according to naKonal surveillance definiKon

¤  Protocol for prevenKng SSI did not differ during the two years in which the study was conducted (?)

Charehbili Surg Infect 2014;15:DOI: 10.1089/sur.2012.185 Charehbili et al. Surg Infect 2014;15:DOI: 10.1089/sur.2012.185

Mimoz et al. Lancet published on-‐line Sept 18th, 2015

¤  11 French intensive-‐care units ¤  PaKents requiring at least one of central-‐venous, haemodialysis, or arterial catheters.

¤  Before catheter inserKon, we randomly assigned paKents to have all intravascular catheters prepared with 2% chlorhexidine–70% isopropyl alcohol or 5% povidone iodine–69% ethanol, with or without scrubbing of the skin with detergent before anKsepKc applicaKon.

¤  Primary outcome was the incidence of catheter-‐related infecKons in the intenKon-‐to-‐treat populaKon.


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Mim

oz et a

l. Lancet p

ublishe

d on

-‐line

Sep

t 18th, 2015


¤  Use of 2% CHX–alcohol for skin anKsepsis was associated with 6-‐fold decreases in the incidences CR-‐infecKon and catheter colonisaKon and a 5-‐fold decrease in the incidence of CR-‐BSI.

¤  Skin scrubbing before anKsepKc applicaKon had no further effect

¤  Adverse skin reacKons were rare but more common with CHX–alcohol than with povidone iodine–alcohol.

Mimoz et al. Lancet published on-‐line Sept 18th, 2015 Prag et al. APMIS 2014;122:961-‐7

¤ Decreased suscepKbility to chlorhexidine was found in 54% of PJI isolates, 68% of cardiac isolates, 21% of commensal isolates, and 7% of skin isolates from cardiac paKents, respecKvely.

¤ The qacA/B gene was found in 52% of PJI isolates, 61% of cardiac isolates, 25% of commensal isolates, and 19% of the skin isolates.

Prag et al. APMIS 2014;122:961-‐7 Steed et al. Am J Infect Control 2014

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Steed et al. Am J Infect Control 2014 Steed et al. Am J Infect Control 2014

¤  Very effecKve in reducing the bacterial load, but …

¤  … 2 hours a_er last applicaKon: what is the bacterial load in the next morning?

¤  … no informaKon about effect a_er mulKple day use (load reducKon?, side effects?)

¤  … no informaKon on the percentage of HCWs that became MRSA-‐free

Bryce et al. J Hosp Infect 2014; doi: 10.1016/j.jhin.2014.06.017. [Epub ahead of print]

¤  Hand hygiene

¤  Environment & maschines/scopes

¤  FighKng MDROs


¤  SSI & OperaKng Room

Merollini et al. AJIC 2013 in press

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Conclusion ¤ PrevenKng deep SSI with anKbioKc prophylaxis and anKbioKc-‐impregnated cement has shown to improve health outcomes among hospitalized paKents, save lives, and enhance resource allocaKon.

¤ Based on this evidence, the use of laminar air operaFng rooms is not recommended.

Merollini et al. AJIC 2013 in press Gastmeier et al. JHI 2012;81:73-‐78

Leape NEJM 2014; 370:1063-‐64

Urbach et al. NEJM 2014; 370:1029-‐38

¤  InformaKon on the use of surgical safety checklists from 130 of 133 hospitals

¤  200,000 surgical procedures

¤  Inclusion of 3 months before the introducKon of a surgical checklist, and one starKng 3 months a_er the introducKon of the checklist

Urbach et al. NEJM 2014; 370:1029-‐38

Urbach et al. NEJM 2014; 370:1029-‐38

¤  It is not the act of Kcking off a checklist that reduces complicaKons, but performance of the acKons it calls for

¤  Implement the behavioral change ² demonstrate the need for change, engage leadership, provide training

in teamwork, make HCW accountable

¤  Provide local teams with direcKon, coaching, training, data management, opportunity to learn from others

¤  “Gaming” ¤  Full implementaKon needs Kme

Leape NEJM 2014; 370:1063-‐64

“The likely reason for the failure of the surgical checklist in Ontario is that it was not actually used”

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¤ RCT of non-‐emergency cardic surgery in 17 UK centers

¤ If hemoglobin level <9g/dl randomly assigned to one of the study groups: ² Liberal transfusion threshold: Hb < 9 g/dl ²  ResitricKve transfuion threshold: Hb < 7.5 g/dl

Murphey et al. NEJM March 2015;372

¤ Serious infecKon (sepsis or wound infecKon) or an ischemic event occurred in 35.1% of the paKents in the restricKve-‐threshold group and 33.0% of the paKents in the liberal-‐threshold group (odds raKo, 1.11; 95% confidence interval [CI], 0.91 to 1.34; P=0.30).

¤ There were more deaths in the restricKve-‐threshold group than in the liberal-‐threshold group (4.2% vs. 2.6%; hazard raKo, 1.64; 95% CI, 1.00 to 2.67; P=0.045).

Murphey et al. NEJM March 2015;372

Schweizer et al. JAMA 2015;313:2162

¤ Evaluate implementaKon of SSI bundle in 20 hospitals in 9 US states

¤ Primary outcome deep and organ space infecKons

¤  Bundle (screening, decolonizaKon and profylaxis) achieved a moderst, staKsKcally significant effect

Schweizer et al. JAMA 2015;313:2162

Schweizer et al. JAMA 2015;313:2162 Bebko et al. JAMA Surgery 2015;150:390

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EducaKonal video CHX washcloths CHX oral rinse Nasal povidone-‐iodine

Bebko et al. JAMA Surgery 2015;150:390 Bebko et al. JAMA Surgery 2015;150:390

Bebko et al. JAMA Surgery 2015;150:390

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