Seven strategies to prevent hospital associated infections improved.pptx

Hospital associated infections need special attention. Seven strategies are suggested to reduce the high prevalence of hospital associate infections.

1. Seven strategies to prevent hospital associated infections Prof. Ashok Rattan, MD,MAMS Ex Laboratory Director, CAREC PAHO/WHO, Ex Secretary, Hifcom , AIIMS, New Delhi Ex Secretary, Infection Prevention & Control, Medanta The Medicity , Gurgram

2. 1. 2. 3. 4. 5. 6. 7. Massino Sartelli

3. Study of effectiveness of nosocomial infection control SENIC LRTI SSI UTI BSI Total

4. Target ZERO Healthcare Associated Infections Zero tolerance for preventable healthcare associated infections & inappropriate practices

5. Infection control objectives for healthcare workers should be an integral part of a healthcare organization's overall program for infection prevention & control Objectives: 1. Educating personnel about the principles of infection control and stressing individual responsibility for infection control 2. Collaborating with the other departments in monitoring and investigating potentially harmful infectious exposures and outbreaks among personnel 3. Providing care to personnel for work-related illnesses or exposures 4. Identifying work-related infection risks and instituting appropriate preventive measures 5. Containing costs by preventing infectious diseases that result in absenteeism and disability

6. Infection Prevention & control is a critical concern for Patients (clients), healthcare workers, facility administrators, and government agencies. Infection control measures are designed to combat everything from the spread of colds and flu to hepatitis B and C, SARS, HIV/AIDS, and other potentially life threatening diseases.

7. Appropriate infection control measures may range from something as simple as following proper hand washing hygiene to coordinated policies involving worker health screening, immunization, and treatment. All these measures should be incorporated into synchronized, organization-wide infection control programs at healthcare facilities of all sizes and types.

8. INFECTION CONTROL TRAINING Infection Prevention & control needs to be everyone's concern Training Goals Ensure that health professionals understand how blood-borne and other pathogens can be transmitted in the work environment: patient to healthcare worker, healthcare worker to patient, and patient to patient Apply current scientifically accepted infection control principles as appropriate for the specific work environment Minimize opportunity for transmission of pathogens to patients and healthcare workers

9. Element II Modes and mechanisms of transmission of pathogenic organisms in the healthcare setting and strategies for prevention and control. The Chain of Infection 1. A pathogen or causative (infectious) agent 2. The reservoir 3. A portal of exit from the reservoir 4. A mode of transmission 5. A portal of entry into a host 6. A susceptible host

10. Reservoir :   Any person, animal, arthropod, plant, soil, or substance (or combination of these) in which an causative agent normally lives and multiplies, on which it depends primarily for survival, and where it reproduces in such numbers that it can be transmitted to a susceptible host. Reservoirs are usually wet Ill people. Well people. Our normal flora (the germs we live with) include bacteria that can be pathogens if they get into the wrong part of the body. For example, our mouths contain many different kinds of bacteria. Raw meat; may harbor pathogens Soil; has rich microbial life which may include pathogens. Water from fish tanks or flower vases; may contain pathogens, especially for compromised patients.

11. HUMAN RESERVOIRS AND TRANSMISSION OF INFECTIOUS AGENTS Reservoir Transmission Vehicle Infectious Agent Blood Blood, needle stick, other contaminated equipment Hepatitis B and C; HIV/AIDS, S. aureus , S. epidermidis Tissue Drainage from a wound or incision S. aureus, , E. coli , Proteus spp Respiratory tract Droplets from sneezing or coughing Influenza viruses , Strep spp . , S. aureus, SARS CoV 2 Gastrointestinal tract Vomitus, feces, bile, saliva Hepatitis A, Shigella spp , Salmonella spp , Rota virus Urinary tract Urine E. coli , enterococci Reproductive tract and genitalia Urine and semen N. gonorrhoeae , T. pallidum , Herpes simplex virus type 2, Hepatitis B

12. Portal of exit .   The way the causative agent gets out of the reservoir. In a person, this is often by a body fluid, and some bacteria, such as MRSA, can live and grow on the skin. Actions we take to reduce risk from portals of exit include: Covering coughs and sneezes with a tissue Handling body fluids with gloves, then doing hand hygiene Keeping draining wounds covered with a dressing Not working when you have exudative (wet) lesions or weeping dermatitis

13. In the community

14. In Modern Hospitals 3/2/2022 15

15. Inside Hospitals Risk of transmission 3/2/2022 16

16. In health care setting commonest means of transmission of infection is by contact

17. Structure of Hospital Infection Prevention & Control HIFCOM MS / Director = Chairman Microbiologist = Secretary Clinicians +one from every team Nursing Superintendent Infection Control Nurses Allied Health care staff Policy making & approving group Meets once a month IPC TEAM Microbiologist = team leader Pharmacologist Epidemiologist (if available) Infection control nurses Lab technicians Policy implementation group Daily work Inform HIFCOM sos

18. Hand Washing

19. Staphylococcus aureus

20. Which bacteria is this ? Escherichia coli

21. Ignaz Semmelweis, 1815-1865 Father of Infection Control

22. Ignaz Semmelweis, 1815-1865 1840’s: General Hospital of Vienna Divided into two clinics, alternating admissions every 24 hours: First Clinic: Doctors and medical students Second Clinic: Midwives

23. The Intervention: Hand scrub with chlorinated lime solution Hand hygiene basin at the Lying-In Women’s Hospital in Vienna, 1847 .

24. Hand Hygiene: Not a New Concept Semmelweis’ Hand Hygiene Intervention ~ Hand antisepsis reduces the frequency of patient infections ~ Adapted from: Hosp Epidemiol Infect Control, 2 nd Edition, 1999.

25. Ignaz Semmelweis, 1815-1865 Father of Hand Hygiene concept to prevent infection Was Clinical assistant at that time Demoted Rediculed Committed to Viennese Insane asylam Died in 1865 age 50

26. Take home message from Ignaz Semmelweis’ life Just because you are right, Donot expect HCW to follow you and your good advice

27. Responsibility of ALL HCW to adhere to scientifically accepted principles and practices of infection control and to monitor the performance of those for whom the professional is responsible. In USA, 1.7 million patients get infected in hospitals while being treated for other ailments and 99,000 die as a consequence . Indian data is incomplete, scantly & unavailable In AIIMS, newspaper indicate HAI have fallen from 20% to 7% HAI not only cause increased mortality, but leads to increased hospital stay and cost USA 5 billion $ HAI: Infections acquired by patients during their stay in hospitals. These infections are neither present nor incubating at the time of admission (they may appear after discharge) For convenience, infections that appear after 48 hrs of stay in the hospital are considered as HAI

28. Deaths in USA due to medical error are Equivalent to ONE Fully loaded Jumbo jet crashing every day of the year

29. Hospital Acquired Infections Hospital Associated Infections Nosocomial Infections Parato Principles 5 pathogens Escherichia coli Staph aureus Pseudomonas aeruginosa Acinetobacter baumanni Klebsiella pneumoniae 5 x 4 4 sites UTI SSI RTI HAP VAP BSI

30. Hospital Associated Infections

31. Preventable Infections and costs of getting it wrong

32. Environmental Hygiene

33. Use engineering and work practice controls to reduce the opportunity for patient and healthcare worker exposure to contact with potentially infectious material in all healthcare settings for blood-borne pathogens. The OSHA Blood-borne Pathogens Standard requires the use, in this order , of: 1. Engineering controls 2. Work practice controls 3. Personal protective equipment

34. Engineering control Engineering controls used to prevent transmission of airborne infections include: Isolation rooms with appropriate air exchanges (negative pressure and/or direct exhaust) HEPA filtration Ultraviolet irradiation Safety sharps devices and containers are another type of engineering control, since they isolate or contain the hazard—used sharps. Giving injections, disposing syringes with needles, or reprocessing needles and other sharps all hold potential risk for exposure to pathogens. The average risk of transmission from a single needle-stick contaminated with HIV has been estimated to be approximately 0.3%. hepatitis B ranges from 1% to 30%, hepatitis C is 1.8 %.

35. Work Practice Controls General Practices Prompt cleanup of blood and body fluid spills with appropriate disinfectant Proper disposal/handling of blood and body fluid, including contaminated patient-care items Safe handling of used linen and waste Specific Practices Using care in the handling and disposal of needles and other sharps Not recapping unless absolutely medically necessary and then using one-hand technique or safety device to recap Disassembling sharp equipment by using forceps or other devices Closing and replacing sharps containers when they are full (rather than overfilling) according to the manufacturer's instructions

36. Spalding Classification for disinfection & sterilization

37. Actions we take to eliminate the mode of transmission include : Hand hygiene Wearing gloves to minimize contamination of hands and discarding them after each patient Maintaining Contact, Droplet and Airborne Precautions as indicated. Cleaning, disinfection, or sterilization of equipment used by more than one patient Cleaning of the environment, especially high-touch surfaces

38. Portal of entry .   The break in the skin that allows the infectious agent to get into the body. Common portals of entry include the mouth, nose, eyes, rashes, cuts, needle-stick injuries, surgical wounds and IV sites . Examples of portals of entry include: Mouth, nose, and eyes Other anatomical openings Skin breaks (cuts, rashes) Surgical wounds Intravenous sites Anatomical openings with tubes in place (more susceptible than those without) Needle puncture injuries

39. Actions we take to protect portals of entry (our own and our patients) include : Dressings on surgical wounds IV site dressings and care Elimination of tubes as soon as possible Masks, goggles and face shields Keeping unwashed hands and objects away from the mouth Actions and devices to prevent needle-sticks Food and water safety

40. Susceptible host .   A person or animal lacking effective resistance to a particular infectious agent.

41. Preventing the spread of infectious organisms includes : Using Standard Precautions with every patient so that precautions are used with unknown carriers of most diseases. Prompt isolation of the patient when indicated, using the appropriate type of precautions. Early identification of the infectious organism and initiation of appropriate treatment

42. Standard Precautions

43. Standard Precautions

44. Standard Precautions

45. Transmission Based Precautions PRECAUTIONS Standard Precautions Specific Precautions

46. Transmission Based Precautions

47. Prevention of spread of infection Screening & cohorting of patients

48. Surveillance : Ongoing systematic collection & analysis of health data essential to planning, implementation & evaluation of public health practices . A. Langmuir 1963 Strategies 1. Active vs Passive 2. Clinical vs Laboratory based 3. Retrospective vs Prospective Methods 1. Hospital wide 2. Limited period 3. Prevalence 4. Targeted

49. WHAT Facility-based HAI surveillance should be performed to identify the most frequent HAIs and detect HAI outbreaks, including AMR surveillance. Timely feedback of results should be provided to health care workers and managers, as well as through national networks, and should guide IPC interventions. • Surveillance should be an essential and well-defined component of the IPC programme . • Adequate microbiology laboratory capacity is needed to support surveillance.

50. WHY • Surveillance of HAI and AMR can provide critical information on the incidence and prevalence of HAIs and AMR in health care facilities (that is, identify “the problem”) to: guide IPC strategies and priorities and assess the effectiveness and impact of interventions; develop benchmarking and assess trends over time; detect clusters or outbreaks of importance and inform wider public health decision-making and actions; assist national decision-makers and the IPC national team to identify priorities for IPC; and develop targeted evidence-based standards and policies. • Evidence has shown significant reductions in HAI rates after the implementation of HAI surveillance programmes , including mechanisms for timely feedback.

51. WHEN • An approach to the surveillance of HAIs should be considered during the establishment of your IPC programme . However, the implementation sequence of the core component recommendations for evidence-based guidelines, education and training, monitoring, audit, feedback and surveillance should be determined according to the specific local context. • While it is recognized that HAI surveillance can provide critical information on the magnitude of the problem for awareness-raising and could be useful from the start of the implementation sequence, it is important to recognize that surveillance requires expertise, laboratory capacity and an established IPC programme and thus, may require time to set up.

52. WHO The responsibility for planning and conducting surveillance and analyzing, interpreting and disseminating the collected data rests usually with the IPC committee and the IPC team. • The named person responsible for surveillance (usually the IPC focal person/lead) should be trained in basic epidemiology, surveillance and IPC. • Epidemiologists, statisticians, data managers and information technology experts with the appropriate capacity to accurately and efficiently collect, analyze and interpret data at the facility • In the absence of an IPC team, data collection can still be undertaken by dedicated staff with access to medical documentation, patient charts, laboratory findings, microbiology and virology results and other relevant registries. However, this staff should receive specific training.

53. HOW (1/2) • Health care facility surveillance should be based on national recommendations and standard definitions and customized to the facility needs and priorities according to available resources with clear objectives and methods. If national recommendations and standard definitions are unavailable, international recommendations/definitions should be referred to. • A prioritization exercise should be undertaken to determine which HAI(s) to target for surveillance according to the local context. Possible recommended infections for surveillance in healthcare include: surgical site infections; device-associated infection (for example, catheter-associated urinary tract infections, central line-associated BSI, peripheral line-associated BSI, ventilator-associated pneumonia); clinically defined infections (for example, in the absence of microbiological testing); colonization or infections caused by multidrug-resistant organisms (MDROs) according to local epidemiology; local priority epidemic-prone infections (for example, norovirus, influenza, TB, severe acute respiratory syndrome , Ebola, Lassa fever); infections in vulnerable populations (for example, neonates, those housed in the intensive care unit, immunocompromised individuals, burn patients); infections that may affect health care workers in clinical, laboratory or other settings (for example, hepatitis B or C, HIV, influenza).

54. HOW (2/2) • Reliable surveillance case definitions should be used (that is, defined numerator and denominator according to international definitions [United States Centers for Disease Control and Prevention National Healthcare Safety Network [CDC/NHSN]/European Centre for Disease Prevention and Control [ECDC]] or locally adapted definitions through an evidence-based adaptation process and expert consultation). • Active surveillance should be used to detect infections. Different surveillance strategies could include the use of prevalence or incidence studies with clear and focused data collection forms. • Surveillance reports should be disseminated in a timely manner to those at the managerial or administration level (decision-makers) and the unit/ward level (frontline health care workers). • Informatics support to conduct surveillance should be in place (for example, equipment, mobile technologies, electronic health records). • A system for surveillance data quality assessment is of the utmost importance (for example, assessment of case reports, review of microbiology results, denominator determination, etc.). Additionally, regular evaluation of surveillance should be undertaken in line with current needs and priorities.

55. Antibiotic Stewardship

56. Antibiotic Use Bundle: Initiation bundle : 1. Clinical rationale for antibiotic initiation documented 2. Appropriate samples for smear & culture collected & submitted to the laboratory 3. Antibiotic selected according to local policy & risk group 4. Antibiotic ordered as per plan (name, dose, route, frequency & tentative duration) 5. Removal of foreign body or ID, as appropriate, considered

57. Day 3 bundle : 1. Was an antibiotic plan documented (name, dose, route, frequency & planned duration ?) 2. Review patient’s condition & diagnosis after lab reports ? 3. If positive microbiology results, was there any adaptation : streamlining or discontinuation 4. Was IV -> oral switch considered & implemented 5. Were all four above mentioned steps followed ?

58. Individualizing antibiotic therapy : [ Making sense of MIC ] Parameters of Antimicrobial Activity Potency: MIC MBC Time course of activity Rate of killing & effect of increasing concentration Persistant effects PAE, SMPAE, PALE

59. PK / PD consideration & application Clinical cure Inhibition of non pathogenic bacteria Selection of resistant mutants Toxicity / side effects

60. What the body does to the drug Dosage Regimen Time course of serum levels Time course of levels in tissues Time course of pharma & tox effect Time course of levels at site Time course of antimicrobial activity Absorption Distribution Metabolism Elimination Pharmacokinetics Pharmacodynamics What the drug does to the body & bacteria Pharmacology of Antimicrobial Therapy

61. PK/PD terminology & central role of MIC Serum Conc. (ug/ml) 16 8 4 2 1 0.5 0.25 0.12 0.06 32 C max MIC Time > MIC C max/ MIC AUC / MIC t > MIC

62. PK/PD parameters predictive of success Cmax / MIC > 10 AUC / MIC > 100 T > MIC > 40 % of dosing interval Variables affecting concentration : Volume of distribution (V d ) Clearance (Cl) T ½ = 0.693 x V d Cl

63. PK / PD Parameters of antimicrobial action Cmax /MIC or AUC /MIC >10 >100 Aminoglycosides Fluoroquinolones Metronidazole Daptomycin Ketolides Azithromycin Streptogramin Glycopeptides Amphotericin B Fluconazole T > MIC (>40%) Penicillin Cephalosporins Carbapenems Monobactam Macrolides Clindamycin Oxazolidinones Glycylcyclines Flucytosine

64. Proof of the pudding is in the eating How to convert Good intention into reality ? Dr. Dharmendra Sharma Excel Program Will give free to Microbiologists interested in Using this

65. Home Screen

66.  Circulating cumulative antibiogram will help clinicians choose right empirical therapy Report on individual isolate would help target therapy 

67. Following Guidelines to prevent infection

68. 7 keys to creating a Safety Culture 1. Hazard identification & remediation 2. Recognize safe be haviour 3. Avoid the blame game 4. Use of positive consequences 5. Build trust and relationship 6. Build safety into daily processes 7. Celebrate success often

69. Follow locally developed antibiotic guidelines & clinical pathways Enhance infection prevention & control activities Control source of infection Prescribe antibiotics when they are truly required Prescribe appropriate antibiotic (s) with adequate dosage Reassess treatment when culture results are available Use the shortest duration of antibiotics based on evidence (PCT ?) Educate staff on prudent use of antibiotics Support surveillance of antibiotics resistance & antibiotic consumption