Prevention of Healthcare-associated - PowerPoint Presentation

1. Prevention ofHealthcare-associatedGastrointestinal Infections

2. Learning objectivesList the types of microorganisms that can cause gastrointestinal infections (GI) associated with health care facilities.Define diarrhoea.Identify risk factors for GI infections.Outline methods to prevent GI infections. December 1, 20132

3. Time involved45 minutesDecember 1, 20133

4. IntroductionMany microbes cause GI problemsMost outbreaks caused by viruses NorovirusBacterial gastroenteritis associated with food and/or water Another cause - toxigenic strains of Clostridium difficileFood-borne infections occurEspecially in low resource countries during warmer monthsDecember 1, 20134

5. Key points Critical elements for prevention and control:IsolationContact PrecautionsDecontamination of spillagesAntibiotic stewardship essential to prevent Clostridium difficile infectionsHand hygiene with soap and water in outbreaksIn food production - temperature controlInspection and auditing often reveal deficiencies in practicesDecember 1, 20135

6. DefinitionsDiarrhoea2 or more episodes of watery stools (Bristol Stool Type 7) or3 or more episodes of loose stools (Bristol Stool Type 6) Over a period of 24 hoursAll cases of acute diarrhoea and/or vomiting regarded as potentially infectiousDecember 1, 20136

7. Non-infectious causes of diarrhoeaExclude when investigating infectionslaxative useallergic reactionschemical and physical agentsnasogastric feedinginflammatory bowel diseasesurgery on the gastrointestinal tractconstipation associated with faecal impactionDecember 1, 20137

8. Food-borne outbreakConsidered when two or more persons who have consumed the same food develop gastroenteritis within 24 hours Cases occur in the same ward in short timeCausesCommon vehicle Poor hygiene and non-compliance of practicesDecember 1, 20138

9. Viral gastroenteritis - 1Norovirus, Adenovirus, Rotavirus Vomit major symptom Sudden and projectileElderly most affected Often resolves spontaneouslyImmunosuppressed shed viruses longerDecember 1, 20139

10. Viral gastroenteritis - 2Noroviruses highly infectious TransmissionDirect Hand contactIndirect Contamination of environment, and subsequent contamination of handsDecember 1, 201310

11. Viral gastroenteritis - 3Characteristic of outbreaksShort incubation period 15 to 48 hoursLimited duration of illness 12 to 60 hoursVomiting the key symptomAffect both patients and staffDecember 1, 201311

12. Prevention of outbreaks - 1Admissions with GI symptoms isolated or cohorted immediatelyGloves and apron for all contacts patients and environment Hand washing with soap and water after every contactAlcohol-based hand rub should not be usedNo masksBed linen and clothing changed daily December 1, 201312

13. Prevention of outbreaks - 2Environmental cleaning Perform at least once a day Disinfect (e.g., 1,000 ppm chlorine)Special attention to toilets, bathroom, and bedpans Attention to horizontal and frequently touched surfacesDecontamination of all spillages of vomit and faecesCohorting of staff and patientsDecember 1, 201313

14. Decontamination of all spillages of vomit and faecesWear personal protective equipment Disposable gloves, apron, visor or mask discardAbsorb by paper towels discardWash area Hot water and detergent then disinfect with fresh chlorine solution at 10,000 ppm Hand washingDecember 1, 201314

15. Cohorting of staff and patientsStaff from wards with cases must not work in unaffected areas until 48 hours have elapsed from the last caseAffected staff should be excluded until they have been symptom-free for 48 hours December 1, 201315

16. Prevention of outbreaks - 3Monitor compliance with IP&C practices If cases continue despite intervention, consider closing ward and stopping new admissions Do not transfer patients to unaffected wards unless urgent If so consult IP&C staffVisitorsRestrict Gown or apron Hand hygiene while visiting and hand washing on leavingDecember 1, 201316

17. End of outbreaksIP&C team determines when overExpert opinion: two complete incubation periods without a new caseTerminal disinfection and changing of bed curtains Special attention to bathrooms and toiletsDecember 1, 201317

18. Antibiotic-associated GastroenteritisDiarrhoea common complication in patients Disruption of the flora in intestine Can colonise with Clostridium difficile Can produce exotoxins resulting in mucosal injury and inflammationDecember 1, 201318

19. C. difficile infections Symptoms from mild diarrhoea to pseudomembranous colitis and perforation Risk increases with health care stayAntibiotic use major pre-disposing factor All antibiotics, especially wider spectrum, can predispose Antibiotic stewardship initiatives crucial for preventionDecember 1, 201319

20. Prevention of Antibiotic-associated Gastroenteritis - 1IP&C measures promptly enforcedHygienic interventions Hand hygiene with soap Lack of activity of alcohol on sporesGloves and disposable gowns or apronsDecember 1, 201320

21. Prevention of Antibiotic-associated Gastroenteritis - 2Programme of CleaningCritical to reduce environmental contamination with sporesChlorine-based compounds main productRecently, hydrogen peroxide mist has been used for terminal decontaminationDecember 1, 201321

22. Prevention of Antibiotic-associated Gastroenteritis - 3Isolation of patients as soon as possible in a single room with toiletIf not achievable, cohort Screening or decolonisation not recommendedSingle use items preferred or thorough cleaning/disinfection between patients Disposable rectal thermometersAntibiotic StewardshipDecember 1, 201322

23. Contact PrecautionsDecember 1, 201323

24. Prevention of Food-borne GastroenteritisPrevalence of healthcare-associated Salmonella and Shigella infections 3% and 2.5% respectivelyHepatitis A, Campylobacter, Yersinia also cause food-related illnessThe role of IP&C Teams depends on facilitySimple supervision to a more significant contributionIP&C personnel need to have a clear understanding of effective food hygieneDecember 1, 201324

25. Food HygieneFood pathogens survive and multiply within the temperature danger zone 6°C to 63°CCold food must be served as soon as possible after removal from refrigerationHeating food to 75°C for 1-2 minutes guarantees destruction of any biological hazardCooling of cooked food must be rapidMaintain temperature control until food is servedMaintain hot holding temperatures above 63°CDecember 1, 201325

26. Common causes of food-borne infections Preparing food more than a half day in advanceStorage at room temperatureInadequate coolingInadequate reheatingUndercookingCross contamination from raw to cooked foodContamination from food handlersDecember 1, 201326

27. Food HygieneTraining should include Conditions for temperature and timeEffective personal hygieneEnvironmental hygiene Potential sources of contaminationDecember 1, 201327

28. Hazard Analysis Critical Control Points (HACCP) Pioneered in the 1960s by USA’s National Aeronautics and Space Administration program Incorporated into legislation of food safety both in USA and the EU Evaluates food production to determine hazards that may contaminate foodIdentifies critical control points after which any contamination cannot be reversedPreventive measures monitored and correctedDecember 1, 201328

29. Elements of HACCPRegular equipment cleaning and maintenance Provision of effective hygiene facilitiesSystems to control insects and other pests Temperature controlRegular training for staff on food hygiene December 1, 201329

30. Adapting HACCP to health care food productionDecember 1, 2013Process Concern Prevention Methods ReceptionGrowth of pathogens. Toxin production. Contamination. Temperature control. Storage Stored covered and dated Rotate stockEnsure a pest free environment. Preparation Limit exposure to ambient temperatures. Prepare with clean equipment Separate cooked and raw foods. Wash hands before handling food. Cooking Cook food to 􏰀75°C in thickest part two minutes. Cooling Cool foods as quickly as possible. Refrigerate within 90 minutes. Do not leave at room temperature. Chilled storage Temperature control.Check expiration dates. Consume within three days Store 6 inches above the floor and away from the wall. Use in rotation. Hot holding/ Distribution Keep food hot at >63°C. Reheating Avoid if possible. Reheat to >75°C. Serving Serve as soon as possible Ensure hands and equipment clean. 30

31. Testing of food, environment, and individualsNot required to monitor food safety May be occasions when is usefulConfirmation of microbiological quality and safety Educational tool for behaviour changes among food handlers Semi-quantitative testing of production area simple and low cost E. coli a good indicator to identify poor hygienic food production practicesRoutine testing of food handlers not indicated (e.g. faeces) December 1, 201331

32. What’s on YOUR hands??! Bobulsky G et al, CID 2007; Farr et al, LID 2001December 1, 201332

33. Ward kitchens precautionsKept clean Refrigerators away from direct heat or sunlightTemperature monitoring Items should be labelled, dated, and used within 72 hoursSeparation between raw and cooked itemsPlace cooked above if in the same refrigeratorDecember 1, 201333

34. Kitchen auditingChecklists for every day documentation of critical points Auditing of kitchen practices Including points related to causes of foodborne illness Critical pointsTemperature control Compliance with hygiene practicesItemised audit sheetDecember 1, 201334

35. SummaryThere are many risks of GI infections in health careCan be produced by bacteria and virusesCan be associated with incorrect IP&C practices, excessive antibiotic use and poor food/or water hygieneMost outbreaks caused by viruses and spread by contactDecember 1, 201335

36. ReferencesDecember 1, 2013Lewis SJ, Heaton KW. Stool form scale as a useful guide to intestinal transit time. Scand J Gastroenterol 1997; 32 (9): 920–4. http://informahealthcare.com/doi/abs/10.3109/00365529709011203 And Bristol Stool Scale http://en.wikipedia.org/wiki/Bristol_Stool_Scale Koopmans M. Noroviruses in healthcare settings: a challenging problem. J Hosp Infect 2009; 73:331-7.36

37. ReferencesDecember 1, 2013Chadwick PR, Beards G, Brown D, et al. Management of hospital outbreaks of gastro-enteritis due to small round structured viruses. J Hosp Infect 2000; 45:1-10. http://www.hpa.org.uk/infections/topics_az/norovirus/hospital_norovirus.pdf World Health Organisation. Five keys to Safer Food Manual [online]. 2006. http://www.who.int/foodsafety/publications/consumer/manual_keys.pdf Food and Agriculture Organization of the United Nations. Food Quality and Safety Systems - A Training Manual on Food Hygiene and the Hazard Analysis and Critical Control Point (HACCP) System 1998. http://www.fao.org/docrep/W8088E/W8088E00.htm 37

38. QuizWhich of the following is effective to prevent food borne infections? Adopting a HACCP system in food productionEnsuring stringent temperature control when storing foodAvoiding preparing food too far in advanceAll of the aboveWhich of the following is NOT a strategy to prevent transmission of diarrhoea by Clostridium difficile? Antimicrobial prophylaxis for all surgical operationsUsing narrow spectrum antibiotics where possibleContact precautions for all cases of diarrhoeaEducation of staff in infection prevention and antibiotic stewardshipLaboratory testing of food handlers is indicated when?NeverTo create awareness in workersTo know epidemiology and causes of infectionsTo identify potential risksDecember 1, 201338

39. International Federation of Infection ControlIFIC’s mission is to facilitate international networking in order to improve the prevention and control of healthcare associated infections worldwide. It is an umbrella organisation of societies and associations of healthcare professionals in infection control and related fields across the globe . The goal of IFIC is to minimise the risk of infection within healthcare settings through development of a network of infection control organisations for communication, consensus building, education and sharing expertise. For more information go to http://theific.org/December 1, 201339