Transcript Infection Control

What You Need to Know
1
 Bacteria
and viruses are most
commonly transmitted on the
hands of health care workers
2
The
single most important way to
prevent the spread of these
organisms is good hand hygiene
3
Good
hand washing
Using alcohol hand gels
Hand care (lotions, cover cuts)
Taking care of dermatitis
 Reporting of skins lesions or
rashes to your Manager and
Employee Health
4
When
hands are visibly dirty or
contaminated
Before and after patient care
Before eating
After using the restroom
Before donning sterile gloves
After removing gloves
If moving from a contaminated body
site to a clean body site during patient
care
After contact with inanimate objects
(including medical equipment)
5
When
hands are visibly soiled
Before eating
After using the restroom
When caring for patients
with C. Difficile
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Coagulase
positive staph/Staph
aureus resistant to
Oxacillin/Methicillin (MRSA)
Coagulase negative or positive staph
resistant to vancomycin
Strep GrD enterococcus resistant to
vancomycin (VRE)
Strep pneumoniae highly resistant to
penicillin (MIC>2)
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 Resistant/Intermediate
to:
 All aminoglycosides (amikacin,
gentamicin, and tobramycin.
 All cephalosporins (cefazolin, cefepime,
ceftazidime, etc.
 All penicillins (ampicillin, pipercillin,
pip/tazo, ampicillin/sulbactam, etc.)
 Imipenem or meropenem
 All isolates of Stenotrophomonas
 ESBL producing bacteria
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Source: Urine
Collected: 09/05/07 01:45
Site:
Received : 09/05/07 01:45
Culture Urine
FINAL 09/08/07 11:31
Organism
01 Escherichia coli
>100,000 cfu/ml
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This organism is an Extended Spectrum b-Lactamase (ESBL) producer.
Consultation with ID specialist is suggested.
Organism
02 Mixed Flora
10,000-20,000 cfu/ml
_____________________________________________________________________________
Organism
E.coli
ANTIBIOTIC
MIC INTRP
_____________________________________________________________________________
Amikacin
16
S
Ampicillin
>=32
R
Cefazolin
>=64
R
Cefepime
>=64
R
Ceftriaxone
>=64
R
Cefuroxime-Sodium
>=64
R
Gentamicin
>=16
R
Imipenem
<=1
S
Levofloxacin
>=8
R
Piperacillin
>=128 R
Piperacillin/tazobactam
8
S
Tobramycin
>=16
R
Trimethoprim/Sulfa
<=20
S
Nitrofurantoin
<=16
S
_____________________________________________________________________________
S=SUSCEPTIBLE
I=INTERMEDIATE
R=RESISTANT
_____________________________________________________________________________
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Source: Blood
Collected: 06/17/09 08:03
Site:
Received : 06/17/09 09:41
Culture Blood
FINAL 06/21/09 11:00
06/19/09 Gram Stain: Gram Positive Cocci in Clusters
Organism
01 Staphylococcus (coagulase negative)
. . . . . . . . . . . . .
Macrolide resistant Staphylococcus aureus and Coagulase Negative
Staphylococcus may have inducible resistance to clindamycin. If
clindamycin is needed, contact Microbiology for further testing.
Plates will be held 3 days after culture is completed.
_____________________________________________________________________________
Organism
ScoagANTIBIOTIC
MIC INTRP
_____________________________________________________________________________
Erythromycin
>=8
R
Gentamicin
<=0.5 S
Levofloxacin
>=8
R
Oxacillin MIC
>=4
R
Penicillin-G
>=0.5 R
Vancomycin
2
S
_____________________________________________________________________________
S=SUSCEPTIBLE
I=INTERMEDIATE
R=RESISTANT
_____________________________________________________________________________
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Source: Urine, Routine
Collected: 05/02/09 01:48
Site:
Received : 05/02/09 01:48
Culture Urine
FINAL 05/27/09 10:00
Organism
01 Acinetobacter baumannii complex
>100,000 cfu/ml
There are no CLSI (NCCLS) interpretive standards for the organism/drug
combination of Acinetobacter sp./tigecycline.
Tigecycline is a restricted antibiotic. Infectious disease consult
required.
Testing of colistin, polymixin B, and tigecycline performed by:
ARUP Laboratories
500 Chipeta Way
Salt Lake City, UT 84108
1-800-522-2787
Organism
02 Enterococcus faecium - (Group D)
>100,000 cfu/ml
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This organism is a VANCOMYCIN RESISTANT ENTEROCOCCUS (VRE)
_____________________________________________________________________________
Organism
A.bau cpx
E.faeci
ANTIBIOTIC
MIC INTRP MIC INTRP
_____________________________________________________________________________
Amikacin
>=64
R
Ampicillin/sulbactam
>=32
R
Cefepime
>=64
R
Ceftazidime
>=64
R
Gentamicin
>=16
R
Levofloxacin
>=8
R
>=8
R
Meropenem
<=4
S
Piperacillin
>=128 R
Tobramycin
>=16
R
Colistin
0.12
S
Polymyxin B
0.25
S
Penicillin-G
>=64
R
Linezolid
2
S
Vancomycin
>=32
R
Nitrofurantoin
128
R
_____________________________________________________________________________
S=SUSCEPTIBLE
I=INTERMEDIATE
R=RESISTANT
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 MRSA
in dry conditions –
 Plastic charts – 11 days
 Laminated tabletop – 12 days
 Cloth curtains – 9 days
 VRE
 50% survival at 7 days on upholstery,
furniture and wall coverings
 Could be transferred easily by touching
contaminated surfaces
Huang et al., Infect Control Hosp Epidemiol
2006; 27:1267-69
Lankford et al., Am J Infect Control 2006;
34: 258-63
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A
patient with a resistant organism is
placed on Contact Precautions by
nursing staff
 When lab calls
 When Infection Control calls
 By physician order
 Per isolation guidelines
 Patient can be placed on Contact
Precautions without a physician order
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 Consists
of:
 Private room
 Stop sign and
Contact
Precautions sign
outside the door
 Gloves to enter
the room
 Gown
for
contact with
patient or
environment
 Dedicated
equipment
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 Infection
Control places a
Precautions Worksheet and a
yellow Contact Precautions sticker
on the chart
 Patient is maintained on
precautions until clearance
criteria are met
 Notify Infection Control before
discontinuing Contact
Precautions
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No Special Precautions Required Rationale: ____________________________
ED
I.C.
CONTACT PRECAUTIONS – Private Room/Gowns/Gloves
MRSA
RULE-OUT MRSA
Hx of MRSA
VRE
C.diff
RULE-OUT C.diff
RESISTANT GRAM NEGATIVE RODS
SCABIES/LICE
SHINGLES LOCALIZED IN IMMUNOCOMPETENT PATIENT
OTHER_________________
RESPIRATORY “DROPLET” PRECAUTIONS – Surgical Mask/NO Neg Air Flow
MENINGITIS
RULE-OUT MENINGITIS
INFLUENZA
RULE-OUT INFLUENZA
OTHER _________________
RESPIRATORY “AIRBORNE” PRECAUTIONS – N-95 TB Mask/Neg Air Flow
TB
RULE-OUT TB
CHICKENPOX
SHINGLES DISSEMINATED OR IN IMMUNOCOMPROMISED PATIENT
OTHER_________________
Pl
PLEASE DO NOT THIN
Notify Infection Control Specialist before discontinuing Precautions
MAINTAIN THIS WORKSHEET IN FRONT OF CHART
SEND WITH CHART IF PATIENT TRANSFERRED WITHIN THE HOSPITAL
NOT PART OF THE PERMANENT MEDICAL RECORD
DISCARD THIS FORM AFTER PATIENT DISCHARGE
<PLACE PATIENT LABEL HERE>
COMMUNITY MEDICAL CENTER
PRECAUTIONS WORKSHEET
5/11//09 JB
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Criteria for Discontinuing Contact Isolation
Reason for Isolation
+ MRSA during current
Hospitalization
Or Hx MRSA
Rule Out MRSA
+ VRE during current
Hospitalization or
Hx of VRE
+ C.diff during current
Hospitalization
Rule Out C.diff
Discontinuing Criteria
After completion of antibiotic therapy:
 2 negative cultures of the original source(s) of positive culture(s)
48 hours apart, OR
 If culturing of original infection source not possible/feasible, ie
wound closed, no sputum production, blood was the original
source, etc.:
o 1 negative MRSA Nasal Screen (NICU pts = 1 negative
MRSA Nasal and Rectal Screen)
Negative culture of suspected MRSA site, ie wound, sputum, urine, etc.
Clearing for VRE cannot be initiated until completion of antibiotic
therapy and:
 2 negative cultures of the original source(s) of positive culture(s)
48 hours apart, OR
 Culturing of original infection source not possible/feasible, ie
wound closed, no sputum production, blood was the original
source, etc.
AND
 2 negative stool VRE Surveillance screens 48 hours apart
After completion of antibiotic therapy:
 If patient no longer has s/s of C.diff (ie diarrhea)
 If patient still has diarrhea, 1 negative C.diff.
 1 negative C.diff prior to or during 1st 48 hours of antibiotic
therapy, unless endoscopy shows colitis.
 C.diff ordered but patient not having bowel movements to
obtain specimens.
Comments
Patients with rectal tubes
are considered to be still
having diarrhea.
If patient not having stools,
notify RN to contact MD to
discontinue orders for
C.diff.
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Required
for diseases that are
spread by:
 Small particles of evaporated
droplets that remain suspended
in the air for long periods of
time
 Dust particles contaminated
with an infectious agent
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 Private
room with Negative Air Flow
 Place blue Respiratory “Airborne”
Precautions and Stop Sign on the door
 Wear N-95 mask
 Put on mask prior to entering the room.
 Take off mask after exiting the room.
 Must be fit-tested to wear N-95 Mask.
 Keep the room door closed
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COMMUNITY MEDICAL CENTERS
RESPIRATORY
Airborne Precautions
Private Room / Negative Air Flow Room / N-95 TB Mask
Notify Infection Control before Airborne Precautions are discontinued.
 Put on N95 mask before entering the patient
room.
 Wash hands or use alcohol hand gel before
leaving room.
 Remove mask after leaving room.
 Keep the room door closed.
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Diseases
that require Airborne
precautions:
 Tuberculosis
 Chickenpox
 Disseminated Shingles
 SARS/Avian Flu
34
For
patients placed on Airborne
Precautions, Infection Control will –
 Place a Precautions Worksheet
and a blue Respiratory “airborne”
Precautions sticker on the chart
Respiratory “airborne” Precautions
can be initiated without a physician
order
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 Prevalence
in Fresno County = 100 new
cases/year
 Screening of patients for TB:
Signs/Symptoms
•Cough>3weeks
•Fever
•Weight loss
•Bloody sputum
•Night sweats
•Suspicious chest
•X-ray
Risk Factors
•Immunocompromised
•History of TB
•Recent exposure
•Recent immigration from
or travel to an area with
a high rate of TB
•Homelessness
•Spent time in a
correctional facility
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REVIEW OF PATIENT
INFORMATION REVEALS
POSITIVE*
SYMPTOMS AND
HIGH RISK
FACTORS
POSITIVE
SYMPTOMS* BUT
LOW RISK
FACTORS
NEGATIVE
SYMPTOMS
BUT HIGH RISK
FACTORS**
NEGATIVE
SYMPTOMS
AND/OR LOW
RISK FACTORS
INITIATE
RESPIRATORY
PRECAUTIONS~AND
RULE OUT ACTIVE
TB
CHEST X-RAY
EVALUATE
CLINICALLY
EVALUATE
ONLY IF
CHANGE
CLEAR/NEGATIVE
FOR TB: NO NEED
FOR RESPIRATORY
PRECAUTIONS
UNLESS
ADDITIONAL
CONCERNS ARISE
POSITIVE/SUSPIC
IOUS FOT TB:
INITIATE
RESPIRATORY
PRECAUTIONS –
AND RULE OUT
ACTIVE TB***
NO NEED FOR
RESPIRATORY
PRECAUTIONS
UNLESS
ADDITIONAL
CONCERNS
ARISE
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 For
patients with a suspicion of TB –
 Infection Control will review the
medical record
 A Tuberculosis
Suspect Case Report will
be completed by Infection Control and
faxed to the Public Health Department
(PHD)
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With
submission of “Suspect”
report form to the PHD, patient
will be placed on a Public Health
Department “HOLD”
Patient MAY NOT be discharged
without written consent of the
County TB Controller or designee
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Infection
Control will notify the
appropriate Case Manager/Discharge
Planner when a patient is put on
precautions and placed on a PHD
“Hold”
Discharge of the patient is arranged
through the Discharge Planner in
collaboration with the PHD
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If
patient wants to leave Against
Medical Advice (AMA) –
 Try to persuade them to stay
 If they insist on leaving, try to get
an address, if possible
 Notify Infection Control and the
PHD or on nights and weekends,
call the Sheriff
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 Required
for diseases that are spread:
 Through the air by large particle
droplets
 Droplets usually travel short
distances, ie less than 3 feet.
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Private
room, NO negative air
flow.
Put on regular surgical mask
before entering the room.
Remove mask before leaving the
room.
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Diseases
that require
Respiratory “Droplet”
Precautions
 Meningitis
 Pertussis (whooping cough)
 Influenza
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Found
in your binder
Lists several
diseases/conditions with
required special precautions
and modes of transmission
Need to be familiar with it to
comply with Infection Control
policies
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Disease
Precautions
Mode of
Transmission
Comments
C.Diff
Contact
Fecal-Oral
Caution with stool.
Do Not Use Hand Gel
Influenza
Droplet-duration
of illness
Droplet
Does not require negative
airflow room; wear surgical
mask
Meningitis
Hemophilus
or Meningo
coccal
Droplet-for 24
hours @ start of
effective ABX
therapy
Droplet
Does not require negative
airflow room; wear surgical
mask; Notify IC and PHD;
Contact EHS or ED if
exposed to patient prior to
initiation of isolation.
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 Over
70 reportable communicable
diseases
 The duty of every health care provider
knowing of, or in attendance on, a case or
suspected case to report on a Confidential
Morbidity Report (CMR) form and fax to
PHD
 CMR generally completed and faxed by
Infection Control
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Anthrax,
Botulism, Smallpox,
Tularemia
Salmonella, Shigella,
Campylobacter, E.coli O157
Sexually Transmitted Diseases:
gonococcal infections, syphilis,
chlamydia
TB
Meningitis: bacterial, viral, fungal
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 MRSA
Screening Program – CA State
 Central Line Insertion Process – CA State
 National Patient Safety Goals - JCAHO
 Hand Hygiene
 Implement Best Practice Guidelines to
decrease central line infections, surgical site
infections and hospital-acquired MRSA/VRE
 Reporting of hospital-acquired infections – CA
State
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
Use soap and water for hand hygiene; DO NOT use an alcohol gel

Use Contact Precautions for patients with confirmed or suspected
C.difficile (i.e., put on gloves upon entering the room; put on
gloves and a gown for any contact with the patient or the
patient’s environment.)

Monitor compliance with Contact Precautions (compliance
monitoring for all patient care providers, including physicians,
began 2/1/10.)

Immediately notify clinical personnel if you suspect a patient has
a C.difficile infection.

Use bleach (Chlorox wipes or bleach solution) to clean the
patient’s room.

Prescribe antibiotics only when necessary.

Educate the patient and patient’s family about C. difficile
infection and prevention strategies. (Education materials soon to
be placed on the Patient/Family Education website on the
Community Forum.)

Utilize the Central Line Insertion Process Bundle:

Perform Hand Hygiene prior to line insertion.

Use Maximal Barrier Precautions:
 Inserter to wear sterile gown, sterile gloves, mask/eye shield, and cap.
 Patient to be covered with a full body sterile drape.

Use a chlorhexidine/alcohol antiseptic (ChloraPrep) for patient skin prep.

Place a chlorhexidine impregnated disc (BioPatch) around the line so it
touches the skin.

Avoid using the femoral vein for central line access, unless absolutely
necessary.

Have all the necessary supplies readily available in a central line kit or cart.

Complete the Central Line Insertion Process (“CLIP”) form/checklist; this is a
CDPH requirement.

Daily, assess and document line necessity and remove if nonessential.

Disinfect catheter hubs, needleless connectors and injection ports with alcohol
before accessing.

Use caps to cover hubs/connectors/ports when not in use.

Change line dressings/caps per hospital policy.

Educate healthcare personnel, patients and their families about central line
related bloodstream infections and prevention strategies. (Education is
available on the Patient/Family Education website on the Community Forum.)

Maintain strict adherence to hand hygiene:
“Gel In & Gel Out”

Use Contact Precautions for patients who are colonized or
infected with MDROs.

Immediately notify Clinical Personnel if you suspect a patient
has an MDRO.

Review the Infection/Isolation tab on the EPIC census to identify
readmitted MDRO patients.

Implement an MRSA screening program for early detection and
isolation of colonized patients. (Program began at CMC in July
2009.)

Prescribe antibiotics only when necessary.

Follow CMC’s Reserved Antimicrobials guideline.

Maintain clean patient care equipment and a clean environment.

Educate healthcare personnel, patients and their families about
MDROs and prevention strategies. (MRSA education is available
on the Patient/Family Education website on the Community
Forum.)

Deliver IV antimicrobial prophylaxis within 1 hour before incision (2
hours for vancomycin and fluoroquinolones.)

Use an antimicrobial prophylactic agent consistent with published
guidelines.

Discontinue the use of prophylactic antibiotic within 24 hours after
surgery (48 hours after cardiothoracic procedures.)

Proper hair removal (i.e., remove hair with clippers or do not remove
the hair at all; razors are not to be used for hair removal.)

Control glucose levels in cardiac surgery patients.

Maintain perioperative normothermia in colorectal surgery patients.

For Class 1 (“clean”) surgical procedures:



Instruct patients to:

Shower with 4% CHG the evening before and morning of the procedure.

Dry a with fresh, clean, dry towel and don clean clothing after each shower.
Screen for MRSA and decolonize if positive
Educate the patient and patient’s family about surgical site infections
and prevention strategies. (Education materials can be found on the
Patient/Family Education website on the Community Forum.)

Beverly Kuykendall, Manager, x52047; Cell 284-1427(CBHC, Dialysis,
Cancer Center, CSTCC, Radiology, Lab, OP Clinics, Home Services, Endoscopy, Surgery and
“Other” ancillary departments or off site facilities)

Connie Young, RN, ICS, x56553; Cell 283-4628 (CRMC 2C, 2E, 6W,
7W, Step
Down Unit, NICU)

Juan Bulgara, RN, ICS, x34436; Cell 348-7441 (4N ICU, 4S ICU, CVU, 5N
ICU, 5S ICU, Burn Center, ED )

Melissa Deen, RN, ICS, x57299; Cell 285-7718 (CRMC 1E, 4C, 4E, 8W, 9W,
L&D, PNU)

Shelli Ashbeck, RN, ICS, (Clovis) x44033; Cell 281-7786 (CCMC, Oakhurst
Urgent Care, )

Karen Stevenson, RN, ICS, CRMC x56508; FHSH 433-8071; Cell—355-5826;
(CRMC)—5E Ante-partum, 5C Peds, 5C M/S, 5W, (FHSH)—Inpatients, Outpatients and
ancillary departments.
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