10/7/2011
BACTERIA TO BED BUGS: INFECTION CONTROL UPDATE Dawn Tomac RN, CIC Director of Quality Avera Health
Bed Bugs to Bad Bugs y Around since the 17th century
S ll ((apple l seed d size) i ) y Small y Oval, flattened shape y Brown-red y Nocturnal y Feed on humans y Some will display symptoms and others will not
http://ohioline.osu.edu/hyg-fact/2000/2105.html
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History y In medieval times bed bugs preferred the rich as
they had the warmest homes y It eventually became a problem for all classes y Until World War II • DDT • Vacuums
y Globalization Gl b li i • Hotels, hospitals, college dorms, airports, and homes
Bed Bugs y Found in dwellings with high occupant turn over
F l b db t l eggs per y Female bed bugs llay ffrom one tto twelve day. Egg to adult takes 21 days y Nymphs and adults can live several months without food. y Need blood meal to molt. y Adult lifespan is 12-18 months
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Bed bugs y Prefer fabric, wood and paper. y Can be found around tufts and seams of
mattresses y They can hide in window and door frames, baseboards, furniture, and more y Bed bugs are not known to transmit disease y Infestations are best handled by licensed pest management professional y Adult bed bugs can crawl 4 feet per minute y http://ipm.ifas.ufl.edu/resources/grants_showcase /people_and_communities/bed_bugs_manual.pdf
Look at the seams.
http://nysipm.cornell.edu/publications/bed_bugs/files/bed_bug.pdf
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Bed bugs y Red, often with darker red spot in middle y Itchy y Arrange in a rough line or in a cluster y Located face, neck, arms and hands y Rarely on trunk-scabies is usually palms, soles,
between the toes and fingers y http://www.mayoclinic.com/health/bedbugs/DS00 663/DSECTION=symptoms
Bed bugs y More a nuisance than medical threat. y Spread slowly by themselves y Inspect your hotel room focusing on the bed y Clean and get rid of clutter y Repair furniture y http://nysipm.cornell.edu/publications/bed_bugs/f
iles/bed_bug.pdf
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Sanitation Measures Frequent vacuuming – check every bed seam and tuft, bed frame,
upholstered furniture, draperies, base boards, carpet next to base board and cracks in furniture Laundering of bedding and clothing • 140 degree hot dryer for 20 minutes • Steam Cleaning • Extreme heat or freezing Vacuum every day • Tilt mattress and box spring and furniture upside down to reach all sides. • Seal vacuum cleaner bag in sealed plastic bag. Place bag in freezer for then di dispose off it. f 24 hours, h th it Bed bugs crawl they do not fly or jump. • Make your bed an island • Bed skirts and linens off the floor • Caulking and barriers on bed legs.
Sanitation y Less toxic types of products now available • Can become resistant to the types of products used • Silica gel dusts Used in wall voids
• Contact your extension office
y Stiff brush can be used to clean mattress seams. y Repair cracks in plaster and glue down wall paper Cornell University: Bed Bugs are back! An IPM answer, 2003
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Questions?
http://www.ca.uky.edu/entomology/entfacts/ef636.asp
MRSA y Around since the 1960’s
H lth A i d y Healthcare Acquired y Community Acquired y Spread by direct contact y Evidence of resistance in animals
http://phil.cdc.gov/phil/quicksearch.asp
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MRSA Community y Different then Health
care acquired y No healthcare stay within last 2 years. y Risk Factors
Healthcare y Associated with stay in
hospital or nursing home y Risk factors
• IV drug use, sports
teams, incarceration, military service
• Multiple
hospitalizations • Renal failure • LTC stay • Frequent Antibiotics
MRSA - transmission y Usually spread by physical contact • Hands • Wounds
y Do not share personal items
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MRSA Survival y 14 days on Formica surfaces y 6 to 8 weeks on cotton-blanket material y Polyester: up to 40 days y Polyethylene: > 51 days y S. aureus remains virulent for at
y after exposure p least 10 days to dry surfaces
VRE Found in feces Majority of them will be E. faecium These organisms can cause UTI’s, biliary infections,
intra-abdominal infections, and bacterial endocarditis Wide spread vancomycin use increases the incidence of VRE Patients admitted to a room of a previous VRE patient are at increase risk of acquiring the bacteria.
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VRE From Hands and Environment y Up to 41% of HCW’s hands sampled (after patient
care and before hand hygiene) y 1 week to 2 months on countertops y 7 days to 4 months on dry polyvinyl chloride surfaces y 1 day to > 3 months on cloth and plastic surfaces
Noskin GA et al. ICHE 1995; 16:577 Bonilla HA et al. ICHE 1996; 17:770 Wendt C et al. J Clin Micro 1998; 36:1998 Neely AN et al. J Clin Micro 2000; 38:724 Noskin GA et al. AJIC 2000; 28:311
Inanimate Environment Can Facilitate Transmission
X represents VRE culture positive sites
Hayden M, ICAAC, 2001, Chicago, IL.
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Acinetobacter baumannii y Defined as multidrug resistance to more than two
of the following five drug classes: y Antipseudomonal cephalosporin's (ceftazidime or y y y y
Cefepime) Antipseudomonal carbapenems (imipenem or meropenem) Ampicillin/sulbactam Fluoroquinolones (ciprofloxacin or levofloxacin) Aminoglycosides (gentamicin, tobramycin, amikacin)
Acinetobacter baumannii y Capable of surviving for extended periods of time
surfaces on inanimate surfaces. y Outbreaks occur, and/or when Acinetobacter survives
due to incomplete cleaning and becomes endemic to the setting. y One outbreak reported was associated with a pulsatile lavage wound therapy. y 50% of outbreaks a source could not be identified.
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Acinetobacter baumannii y Outbreak situations may warrant surveillance
cultures of patients most at risk of six body sites(throat, nose, skin, wounds, rectum, endotracheal aspirates) y Best practice for surveillance cultures is not available
because they have not been verified to be effective. y Surveillance of the environment maybe indicated in an outbreak situation. y In a study of colonizing sites half of the cultures done were positive in a 5 month study. Digestive tract was a major reservoir.
Acinetobacter baumannii y Transmission is most commonly associated with
skin body fluids, fluids equipment or contaminated skin, environment. y Suction equipment, ventilators, shower trolleys,
washbasins, infusion pumps, pillows and mattresses, bedrails, sinks, resuscitation equipment, bedside tables, hygroscopic bandages, and stainless steel carts. t y Hand Hygiene is very Important y Contact Precautions with private room.
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MDRO – Gram Negative Rods y MDRO-GNR(Multi-drug Resistant Gram Negative
Non-ESBL: NonRods) Non ESBL: Pseudomonas Aeruginosa: Non susceptible to Carbapenems (imipenem, meropenem), 3rd and 4th generation Cephalosporins (ceftazidime, cefepime), Aminoglycosides (amikacin, gentamicin, tobramycin), Fluoroquinolones (ciprofloxacin, Levaquin, gatifloxacin), Broad spectrum penicillins (Timentin, piperacillin, Tazidime, aztreonam), and Non-susceptible to all antibiotics except intermediate or sensitive to Amikacin or Aztreonam (ignore Meropenem)
Pseudomonas aeruginosa y Common cause of ventilator associated pneumonia
I h bit moist i t environments i t such h as water, t soil, il y Inhabits and plants y People with cystic fibrosis, burn victims, and other patients in intensive care units are at risk y Not a normal part of a persons flora. y It can cause UTI’s, dermatitis, soft tissue infections, bacteremia and other systemic infections.
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Pseudomonas y In nature it might be found as a biofilm. y It loves to grow at 37 degrees but as high as 42
degrees. y Only a few antibiotics are effective against Pseudomonas, including fluoroquinolones, gentamicin and imipenem. y Accounts for 10 10.1 1 percent of all hospital acquired infections.
Sinks y Dec. 2004 – Mar 2006 36 patients exposed to P. y y y y y
gi i an ICU or transplant t l t unit it aeruginosa in 17 of the infected patients died within 3 months 12 of 17 deaths P. aeruginosa contributed to or directly caused death Source of the outbreak - hand hygiene sink drains, where g biofilms containingg viable organisms were found During hand hygiene contents splashed at least one meter from sink Sink renovation Hota S et al. ICHE 2009 30:25-33
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ESBL Producing Bacteria y Extended Spectrum Beta Lactamase y An enzyme that protects the bacteria from
antibiotics y Two Main bacteria
• Klebsiella pneumoniae • Escherichia coli
• Noted in Enterobacter cloacae, P. aeruginosa, and
Serratia marcescens y Resistant to ceftazidime, cefotaxime, ceftriaxone, aztreonam, cefoxitin, cefotetan and meropenum and imipenem.
ESBL y Have been isolated in abscesses, blood, catheter
tips lung, lung peritoneal fluid, fluid sputum and throat tips, culture. y Generally found after treatment with cephalosporins or through nosocomial transmission. Medical use of antibiotics can p accelerat the selection pressure. y Identifying these are still a challenge.
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ESBL y Risk factors for infection include ICU, recent
surgery instrumentation, instrumentation prolonged hospital stay surgery, and antibiotic exposure. y Especially to extended spectrum beta lactam
antibiotics y The lower GI tract of colonized patients is the main
g g can reservoir of these organisms. This carriage persist for months. y Nursing home residents can be at risk because of treatment with empiric antibiotics.
carbapenem-resistant Enterobacteriaceae y Resistant to almost all antimicrobial agents
Hi h rates t off morbidity bidit and d mortality t lit y High • Most at risk are those critically ill with ventilators and
central lines y Main bacteria involved • Klebsiella pneumoniae (most common) • E. coli
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Carbapenem Resistant Enterobacteriaceae y Carbapenem-Resistant Enterobacteriaceae (CRE) or CRKP
(carbapenem-resistant Klebsiella pneumonia): KPC confers resistance to penicillins, cephalosporins, aztreonam clavulanic acid, and tazobactam, in addition to carbapenems, making treatment of these infections very challenging. This occurs most commonly in Klebsiella pneumoniae. It is also reported in Klebsiella oxytoca, Citrobacter freundii, Enterobacter spp., E.coli, Salmonella spp., and Serratia spp.
Susceptibility Profile of KPC Antimicrobial
Interpretation
Antimicrobial
Interpretation
Amikacin
I
Chloramphenicol R
Amox/clav
R
C f Ciprofloxacin
R
Ampicillin
R
Ertapenem
R
Aztreonam
R
Gentamicin
R
Cefazolin
R
Imipenem
R
Cefpodoxime
R
Meropenem
R
Cefotaxime
R
Pipercillin/Tazo
R
Cetotetan
R
Tobramycin
R
Cefoxitin
R
Trimeth/Sulfa
R
Ceftazidime
R
Polymyxin B
MIC >4μg/ml
Ceftriaxone
R
Colistin
MIC >4μg/ml
Cefepime
R
Tigecycline
S
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y y
Comments: URINE CULTURE FOR POSSIBLE ESBL
--------------------------------------------------------------------------------------------
y
URINE CULTURE Final
y
Organism 1
y
Colony Count
y
MULTIDRUG RESISTANT, ORG.SENSI - WAS REPEATED. SEE TEXT/COMMENT.
y
08/26/11-0943 ENTEROBACTER CLOACAE >100,000 CFU/ML
ENTEROBACTER CLOACAE
y
This isolate has been confirmed as producing a carbapenemase (by the State Health Lab). It is resistant to all betalactam antimicrobials including extended spectrum cephalosporins, cefoxitin and carbapenems. There may be few antimicrobial choices. Consider Infectious Disease consult as clinically indicated. ******************************************************
y
ENT CLOAC
y
Trimethoprim/Sulfamethoxazole
y
Cefazolin
y
Cefoxitin
>=64
y
Ceftazidime
>=64
R
y
Ceftriaxone C ft i
32
R
y
Cefepime
32
R
y
Ciprofloxacin
y
Gentamicin
y
Imipenem
y
Nitrofurantoin
y
Piperacillin/Tazobactam >=128
R
y
Levofloxacin
R
M.I.C.
RX
ABN >=320
R
>=64
R R
>=4 8
R I
>=16 128 >=8
R R
CRE Infection Control y Be aggressive y Implement Contact Precautions
Must Gown and Glove Must practice good Hand Hygiene Clean equipment between patients y Look for others with CRE by doing rectal cultures on
those in close proximity to the index case. If other cases found do weekly surveillance
cultures on patients in same unit.
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Clostridium difficile y Spore forming gram positive organism. y The most common cause of antibiotic
associated diarrhea y Requires two elements
• Exposure to antibiotics • Acquisition of C. difficile by fecal oral route
y Risk Factors • All antibiotics been butt especially tibi ti have h b iimplicated li t d b i ll cephalosporins, clindamycin and fluoroquinolones • Even single prophylactic surgical antibiotics have been implicated.
Clostridium difficile y Environmental surfaces are readily contaminated
y Bleach based disinfectants are
recommended in out break situations; some facilities use it for all cases. y Remember to thoroughly clean surfaces such as commodes y Hand hygiene with soap and water is often an
intervention
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Diagnosis y Testing should only be done on
diarrhea (unformed) stool stool, unless ileus is suspected. (B-II) y Testing of stool of asymptomatic patients is not clinically useful. It is p g onlyy recommended in epidemiological studies (B-III) y Stool culture is the most sensitive test (A-II)
Clostridium difficile y Incubation is not clearly known
days y One study suggested short period < 7 days. y C. difficile infection occurring with in 4 weeks of
hospitalization should be attributed to being health care acquired. As long as no previous infection 8 weeks prior to admission or event.
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Treatment y Discontinue inciting antibiotics as soon as possible
(A II) (A-II) y May influence risk of CDI recurrence y Severe or Complicated CDI is suspected
y Initiate treatment as soon as suspected y If stool toxin assay is negative
y Decision to stop therapy must be
individualized
Treatment y Stop antiperistaltic agents (C-III) y May obscure symptoms y May precipitate toxic mega colon
y Metronidaxole is drug of choice (A-I) for initial mild to
moderate CDI y Vancomycin is drug of choice (B-I) for severe CDI
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Norovirus y Highly contagious-5 billion infectious doses in each y y y y y y y
gram of feces 30 million viral particles in one projectile vomiting incident 10-100 viral particles = infectious dose 21 million illnesses each year Humans only known reservoir Symptoms are diarrhea, vomiting and stomach pain S Anyone can get it and can occur multiple times Most common cause of gastroenteritis in US
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Norovirus y Norwalk agent
Norwalk Ohio in 1968. 1968 y Discovered in a school in Norwalk, y Estimated 5,461,731 infections every year. y 14,663 Hospitalizations y 149 deaths a year
http://www.cdc.gov/foodborneburden/2011-foodborneestimates.html
Norovirus y Dehydration is a problem y Contagious from the moment they feel ill till at least
3 days and as long as 2 weeks y Transmitted by y Eating and drinking contaminated food and liquids y Aerosolized vomitus y Touching and then placing T hi surfaces f d th l i their th i hand h d iin their th i
mouths y Direct contact or when sharing food, drinks
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Norovirus Gets Around Quickly Eating
Drinking People are contagious from the moment they feel ill until 3 days after they recover
Norovirus Control y Wash hands with soap and water (20 seconds) y Carefully wash fruits and vegetables y Do not prepare food when ill and for 3 days after y No bare hand contact with ready to eat y Clean contaminated surfaces with a bleach based
disinfectant y Wash laundry thoroughly
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Norovirus Control y Exclude ill staff (food, child care, patient care
y y y y
workers)) until 48 to 72 hours after symptom y p resolution Isolate ill residents until 24-48 hours after symptom resolution Clean 1:10 dilution of household bleach or premixed formulations Collect whole stool specimens from at least 5 people in the acute phase ( 2 diff differentt b bacterial y 31 carried potentially pathogenic bacteria
y 70% alcohol or liquid soap for membrane
disinfection y No bacteria survived after disinfection
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Mobile Phones y Patients and Visitors y 133 - cultured y 121 - positive cultures y 101 - Coagulase-
negative Staph 42 - MRCNS
y HCW’s y 67 - cultured y 58 - positive cultures y 52 - Coagulase-negative
Staph p
y 18 - S. S aureus 1 - MRSA
y 14 - Strep spp. y 4 - ESBL y 11 - Bacillus spp.
21 - MRCNS
y 4 - S. aureus y 7 - Strep spp. y 2 – Bacillus spp. Tekerekoglu MS. AJIC 39: 370-381
Survival of Pathogens on Environmental Surfaces PATHOGEN
PRESENCE ON SURFACES
C. difficile
> 5 months
Staphylococci
7 months
VRE
4 months
Acinetobacter
5 months
Norovirus
3 weeks
Adenovirus
3 months
Rotovirus
3 months
SARS, HIV
Days to week Hota B Clinical Infectious Diseases 2004;39:1182-9
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Questions?
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