Chain of Infection in pharma industry.PPT

pharma

1. Does the Environment Play a
Role in the Spread of Infection -
and if so
- doing what counts!
Mary Brachman RN MS CIC

2. Presentation Overview

Infection Control ConceptsInfection Control Concepts

Level of DisinfectionLevel of Disinfection

Susceptibility of MicroorganismsSusceptibility of Microorganisms

Factors Affecting DisinfectionFactors Affecting Disinfection

Appropriate DisinfectantsAppropriate Disinfectants

3. Presentation Overview

Controversial IssuesControversial Issues

Antibiotic Resistant OrganismsAntibiotic Resistant Organisms

Blood and Body Fluid SpillsBlood and Body Fluid Spills

Isolation RoomsIsolation Rooms

Adding Value to the Organization Adding Value to the Organization

4. How are organisms
spread and who is
at risk?

5. Infectious Agents
Reservoirs
Portals of Exit
Transmission

Portals of Entry

Susceptible Host
Bacteria
Excretions
Contact
Mucous
membrane
People
Viruses
Secretions
Droplet
Broken Skin
Equipment
Fungus
Skin
Vehicle
GI Tract
Water
Parasites
Droplets
Airborne
GU Tract
Genetic
makeup
Underlying
disease
Environ-
ment
Skin
integrity
Vector
Respiratory
tract

The Chain of Infection

6. Breaking the
Chain of
Infection
Infectious
Agents
Reser-
voirs
Portals
of
Exit
Transmission
Modes
Portals
of
Entry
Suscep-
tible
Host

7. Breaking the
Chain of
Infection
Infectious
Agents
Reser-
voirs
Portals
of
Exit
Transmission
Modes
Portals
of
Entry
Suscep-
tible
Host

8. What’s the
“RIGHT”
Level of Disinfection?

9. Categories of Items Needing
Disinfection or Sterilization
CriticalCritical
SemicriticalSemicritical
Non-CriticalNon-Critical

10. Categories of Items Needing
Disinfection/or Sterilization
CriticalCritical
Enters sterile tissue or Enters sterile tissue or
vascular systemvascular system

11. CRITICAL

12. Categories of Items Needing
Disinfection or Sterilization
SemicriticalSemicritical
Touches mucous Touches mucous
membranes or membranes or
non-intact skinnon-intact skin

13. Semicritical

14. Categories of Items Needing
Disinfection/or Sterilization
Non-CriticalNon-Critical
Touches intact skinTouches intact skin

15. Categories of Items Needing
Disinfection/or Sterilization
Environmental SurfacesEnvironmental Surfaces

Housekeeping surfacesHousekeeping surfaces

Medical equipment surfacesMedical equipment surfaces
Non-Critical

16. Non-critical - housekeeping
surfaces

17. Non-critical - equipment

18. How RESISTANT Are
Microorganisms to
Disinfectants?

19. Descending Order of Resistance
to Chemical Disinfectants
Bacterial SporesBacterial Spores
Bacillus subtilisBacillus subtilis
MycobacteriaMycobacteria
Mycobacterium tuberculosisMycobacterium tuberculosis
Nonlipid or small virusesNonlipid or small viruses
Polio VirusPolio Virus
FungiFungi
Trichophyton spp.Trichophyton spp.
Vegetative BacteriaVegetative Bacteria
Pseudomonas Pseudomonas
StaphylococcusStaphylococcus
Lipid or medium-sized virusesLipid or medium-sized viruses
Hepatitis B Virus (HBV)Hepatitis B Virus (HBV)
Human Immunodeficiency Virus (HIV)Human Immunodeficiency Virus (HIV)
Favero, MS in Block SS.
Disinfection, Sterilization & Preservation, 1991
Hard to kill
Easy to kill

20. Descending Order of Resistance
to Chemical Disinfectants
Bacterial Spores STBacterial Spores ST
Bacillus subtilisBacillus subtilis
HLDHLD
Mycobacteria ILDMycobacteria ILD
Mycobacterium tuberculosis Mycobacterium tuberculosis
Nonlipid or small viruses LLDNonlipid or small viruses LLD
Polio VirusPolio Virus
FungiFungi
Trichophyton spp.Trichophyton spp.
Vegetative BacteriaVegetative Bacteria
PseudomonasPseudomonas
StaphylococcusStaphylococcus
Lipid or medium-sized virusesLipid or medium-sized viruses
Hepatitis B Virus (HBV)Hepatitis B Virus (HBV)
Human Immunodeficiency Virus (HIV)Human Immunodeficiency Virus (HIV)
Favero, MS in Block SS.
Disinfection, Sterilization & Preservation, 1991

21. What factors
influence the
EFFECTIVENESS
of the
disinfection process?

22. Factors Influencing
Disinfectant Activity

Number & location of organismsNumber & location of organisms

Resistance of organismsResistance of organisms

ConcentrationConcentration

23. Factors Influencing
Disinfectant Activity (con’t)

Water hardness and temperatureWater hardness and temperature

Organic matterOrganic matter

Contact timeContact time

24. Characteristics Of An Ideal
Disinfectant

Broad spectrumBroad spectrum

Fast actingFast acting

Good cleanerGood cleaner

Surface compatibilitySurface compatibility

Not affected by environmental factorsNot affected by environmental factors
* Rutala, Wm., in Hospital Epidemiology and Infection Control; Chapter * Rutala, Wm., in Hospital Epidemiology and Infection Control; Chapter
69; 199669; 1996

25. Characteristics Of An Ideal
Disinfectant (con’t)

Residual effectResidual effect

Water solubleWater soluble

Stable in concentrate and use-dilutionStable in concentrate and use-dilution

Easy to useEasy to use

EconomicalEconomical
* Rutala, Wm., in Hospital Epidemiology and Infection Control; Chapter * Rutala, Wm., in Hospital Epidemiology and Infection Control; Chapter
69;199669;1996

26. CONTROVERSIAL ISSUES

Antibiotic Resistant OrganismsAntibiotic Resistant Organisms

Clean Up of Blood & Body Fluids Clean Up of Blood & Body Fluids

Standard Precautions and Standard Precautions and
Isolation RoomsIsolation Rooms

27. Antibiotic Resistant
Organisms
Methicillin ResistantMethicillin Resistant
Staph aureusStaph aureus (MRSA)(MRSA)
Vancomycin ResistantVancomycin Resistant
EnterococcusEnterococcus (VRE)(VRE)

28. Antibiotic Resistant
Organism
A microorganism that has A microorganism that has
developed resistance to developed resistance to
antibioticsantibiotics

29. Resistant Organisms:Resistant Organisms:
Why the Concern?Why the Concern?

Ineffective or no antibiotics
 Poor patient outcomes
 Delayed discharge
 Increased costs

30. Patients Most at Risk for Patients Most at Risk for
Acquiring Resistant StrainsAcquiring Resistant Strains

Multiple medical problems
 Long hospitalizations
 Admitted to intensive care
 Receiving antibiotics

31. Methicillin ResistantMethicillin Resistant
Staph aureusStaph aureus
Reservoir: Reservoir: SkinSkin
Contaminated Contaminated
equipment equipment or surfacesor surfaces
Transmission:Transmission:Direct skin to skin Direct skin to skin
contactcontact
Indirect contact via Indirect contact via
contaminated contaminated
equipment equipment or surfacesor surfaces

Resistance to Disinfectants: LowResistance to Disinfectants: Low

32. Descending Order of Resistance
to Chemical Disinfectants
Bacterial SporesBacterial Spores
Bacillus subtilisBacillus subtilis
MycobacteriaMycobacteria
Mycobacterium tuberculosisMycobacterium tuberculosis
Nonlipid or small virusesNonlipid or small viruses
Polio VirusPolio Virus
FungiFungi
Trichophyton spp.Trichophyton spp.
Vegetative BacteriaVegetative Bacteria
StaphylococcusStaphylococcus
Methicillin Resistant StaphMethicillin Resistant Staph
Lipid or medium-sized virusesLipid or medium-sized viruses
Hepatitis B Virus (HBV)Hepatitis B Virus (HBV)
Human Immunodeficiency Virus (HIV)Human Immunodeficiency Virus (HIV)Adapted from: Favero, MS in Block SS.
Disinfection, Sterilization & Preservation, 1991
Hard to kill
Easy to kill

33. Patient staff . . .
Staff surfaces . . .
Surfaces hands . . .
Hands patient

34. Vancomycin ResistantVancomycin Resistant
EnterococcusEnterococcus (VRE) (VRE)
Reservoir: Reservoir: BowelBowel
Contaminated Contaminated
equipment equipment or surfacesor surfaces
Transmission:Transmission:Direct contact with Direct contact with
fecesfeces
Indirect contact via Indirect contact via
contaminated contaminated
equipment equipment or surfacesor surfaces

Resistance to Disinfectants: LowResistance to Disinfectants: Low

35. Descending Order of Resistance
to Chemical Disinfectants
Bacterial SporesBacterial Spores
Bacillus subtilisBacillus subtilis
MycobacteriaMycobacteria
Mycobacterium tuberculosisMycobacterium tuberculosis
Nonlipid or small virusesNonlipid or small viruses
Polio VirusPolio Virus
FungiFungi
Trichophyton spp.Trichophyton spp.
Vegetative BacteriaVegetative Bacteria
EnterococcusEnterococcus
Vancomycin Resistant EnterococcusVancomycin Resistant Enterococcus
Lipid or medium-sized virusesLipid or medium-sized viruses
Hepatitis B Virus (HBV)Hepatitis B Virus (HBV)
Human Immunodeficiency Virus (HIV)Human Immunodeficiency Virus (HIV)Favero, MS in Block SS.
Disinfection, Sterilization & Preservation, 1991
Hard to kill
Easy to kill

36. Surfaces hands . . .
Hands patient . . .

37. What are the
recommendations for
environmental
cleaning?

38. Environmental CleaningEnvironmental Cleaning
Standard Precautions
“Adequate procedures for
routine care, cleaning and
disinfecting of
environmental surfaces,…
CDC Guideline for Isolation Precautions in Hospitals;
AJIC Vol. 24, pp. 24-52; 1996

39. Environmental CleaningEnvironmental Cleaning
Standard Precautions
…beds, bedrails, bedside
equipment and other frequently
touched surfaces and that
procedures are being followed.”
CDC Guideline for Isolation Precautions in Hospitals;
AJIC Vol. 24, pp. 24-52; 1996

40. Appropriate Disinfectants For
Housekeeping Surfaces - CDC

““visible cleanliness using detergent and visible cleanliness using detergent and
warm water, warm water, oror

EPA hospital grade detergent- disinfectant”EPA hospital grade detergent- disinfectant”
Favero, M. in Chemical Germicides in Health Care; Ch. 4;1995Favero, M. in Chemical Germicides in Health Care; Ch. 4;1995

41. Appropriate Disinfectants For
Non-Critical Equipment - CDC

““detergent and warm water, detergent and warm water, OROR

cleaning plus application of intermediate to low-level disinfectant”cleaning plus application of intermediate to low-level disinfectant”
Favero, M. inFavero, M. in
Chemical Germicides in Health Care; Ch. 4;1995Chemical Germicides in Health Care; Ch. 4;1995

42. Environmental CleaningEnvironmental Cleaning
Airborne Precautions - same as
Standard Precautions
Droplet Precautions -
same as Standard Precautions
CDC Guideline for Isolation Precautions in Hospitals;
AJIC Vol. 24, pp. 24-52; 1996

43. Environmental Cleaning
Contact Precautions -Contact Precautions -

““adequate procedures for routine adequate procedures for routine
care, cleaning and disinfecting…”care, cleaning and disinfecting…”

dedicate non-critical equipment; dedicate non-critical equipment;
clean and disinfect between clean and disinfect between
patientspatients
CDC Guideline for Isolation Precautions in Hospitals; CDC Guideline for Isolation Precautions in Hospitals;
AJIC Vol. 24, pp. 24-52; 1996AJIC Vol. 24, pp. 24-52; 1996

44. Environmental Cleaning
Antibiotic Resistant Organisms
Acute Care Non-Acute Care
Non-Hand
Contact

When visibly soiled &
to maintain aesthetics

Detergent OK

When visibly soiled &
to maintain aesthetics

Detergent
Hand-
Contact

Daily cleaning

Detergent-
disinfectant

Regular cleaning & to
maintain aesthetics

No recommendations
on detergent vs.
disinfectant
ddfdf df
Global Consensus Conference on Antimicrobial
Resistance. March, 1999; Tornoto Canada

45. Environmental Cleaning
Antibiotic Resistant Organisms

Dedicate non-critical equipmentDedicate non-critical equipment

Clean & disinfect between patientsClean & disinfect between patients

Outbreak situations - additional cleaning Outbreak situations - additional cleaning
may be indicatedmay be indicated

Terminal cleaning - opportunity to clean Terminal cleaning - opportunity to clean
areas not routinely accessible areas not routinely accessible
Global Consensus Conference on Antimicrobial Resistance. March, Global Consensus Conference on Antimicrobial Resistance. March,
1999; Toronto Canada1999; Toronto Canada

46. Environmental Cleaning
Antibiotic Resistant Organisms

Identify surfaces frequently touched Identify surfaces frequently touched

Include these surfaces in daily and Include these surfaces in daily and
terminal cleanterminal clean

Review the cleaning processReview the cleaning process

Ensure compliance with proceduresEnsure compliance with procedures

47. OSHA Bloodborne OSHA Bloodborne
Pathogen StandardPathogen Standard
Clean Up ofClean Up of
Blood and Body FluidsBlood and Body Fluids

48. OSHA Bloodborne
Pathogen Standard
““work site maintained in a clean and work site maintained in a clean and
sanitary condition . . . contaminated sanitary condition . . . contaminated
work surfaces shall be decontaminated work surfaces shall be decontaminated
with an with an appropriate disinfectantappropriate disinfectant after after
completion of procedures; immediately completion of procedures; immediately
or as soon as feasible when or as soon as feasible when
contaminated or after any spill of blood contaminated or after any spill of blood
or other potentially infectious or other potentially infectious
materials . . .”materials . . .”

49. OSHA Bloodborne
Pathogen Standard
Appropriate DisinfectantAppropriate Disinfectant
Tuberculocidal (Phenolic)Tuberculocidal (Phenolic)
Sodium Hypochlorite (Bleach)Sodium Hypochlorite (Bleach)
Quat with HIV/HBV claimQuat with HIV/HBV claim

50. OSHA Bloodborne
Pathogen Standard
Must follow label instructionsMust follow label instructions::

Personal protective equipmentPersonal protective equipment

Clean surface before disinfectingClean surface before disinfecting

Leave surface wet:Leave surface wet:

30 seconds HIV30 seconds HIV

10 minutes HBV10 minutes HBV

51. Descending Order of Resistance
to Chemical Disinfectants
Bacterial SporesBacterial Spores
Bacillus subtilisBacillus subtilis
MycobacteriaMycobacteria
Mycobacterium tuberculosisMycobacterium tuberculosis
Nonlipid or small virusesNonlipid or small viruses
Polio VirusPolio Virus
FungiFungi
Trichophyton spp.Trichophyton spp.
Vegetative BacteriaVegetative Bacteria
Pseudomonas Pseudomonas
StaphylococcusStaphylococcus
Lipid or medium-sized virusesLipid or medium-sized viruses
Hepatitis B Virus (HBV)Hepatitis B Virus (HBV)
Human Immunodeficiency Virus (HIV)Human Immunodeficiency Virus (HIV)
Favero, MS in Block SS.
Disinfection, Sterilization & Preservation,
1991
Hard to kill
Easy to kill

52. OSHA Directive Can Be OSHA Directive Can Be
ChallengedChallenged

Non-tuberculocidal disinfectants Non-tuberculocidal disinfectants
(e.g. quats) inactivate HBV(e.g. quats) inactivate HBV

Non-critical surfaces rarely Non-critical surfaces rarely
involved in disease transmissioninvolved in disease transmission

Exposure time manufacturers Exposure time manufacturers
use to achieve label claims are use to achieve label claims are
not used for non-critical surfacesnot used for non-critical surfaces

53. OSHA Directive:
Implications for Practice

Use scientific literature to determine Use scientific literature to determine
practice; use quatpractice; use quat

Risk OSHA citation and fineRisk OSHA citation and fine
At Hospitals Discretion

54. How Do You
Add Value
to the Organization?

55. Cost Analysis - Quat vs Phenolic
Direct costsDirect costs

Labor: salaries and benefitsLabor: salaries and benefits

MaterialsMaterials
fixed costs fixed costs

variable costsvariable costs
Indirect costsIndirect costs

Labor: salaries and trainingLabor: salaries and training

Opportunity costOpportunity cost

Problems associated with procedureProblems associated with procedure

56. Slay the Sacred Cows

Disinfectants for cleaning:Disinfectants for cleaning:

hallways, conference rooms, nurses station, utility roomshallways, conference rooms, nurses station, utility rooms

non-hand-contact surfaces in patient rooms non-hand-contact surfaces in patient rooms (unless more (unless more
practical)practical)

Phenolics for environmental cleaningPhenolics for environmental cleaning

Excessive cleaning of OR walls, floorsExcessive cleaning of OR walls, floors

10 minute contact time for non-critical surfaces10 minute contact time for non-critical surfaces

57. Slay the Sacred Cows

““Special cleaning” for Isolation Rooms Special cleaning” for Isolation Rooms (in (in
absence of visible soil)absence of visible soil)

changing cubical curtainschanging cubical curtains

preparing fresh solution before cleaningpreparing fresh solution before cleaning

discarding solution after cleaning discarding solution after cleaning

changing mop heads changing mop heads

washing walls and stripping floorswashing walls and stripping floors

Wearing scrub apparel for infection controlWearing scrub apparel for infection control

Red bags for “non-infectious” wasteRed bags for “non-infectious” waste

58. Breaking the
Chain of
Infection
Infectious
Agents
Reser-
voirs
Portals
of
Exit
Transmission
Modes
Portals
of
Entry
Suscep-
tible
Host