Infection prevention : new perspectives and controversies

Dedication
Contents
Contributors
1: HAI Controversies: Contact Precautions
	Introduction
	Current Guideline Recommendations for Contact Precautions in Acute Care Facilities
	History of Isolation Precautions
		Vertical Versus Horizontal Infection Control Strategies
		MRSA and the Impact of Contact Precautions
	Vancomycin-Resistant Enterococcus (VRE)
	Contact Precautions for Gram-Negative Rods and Clostridium difficile
	References
2: Hand Hygiene Monitoring Technologies: Implementation and Outcomes
	Introduction
	Monitoring Hand Hygiene Compliance
	Methods for Monitoring HH Compliance
		Direct Observation
		Measuring Product Consumption
		Video Surveillance and Feedback
		Electronic Surveillance and Alerts
	Summary
	References
3: Universal Glove and Gown Use for the Prevention of Methicillin-­Resistant Staphylococcus aureus (MRSA) or Vancomycin-Resistant Enterococcus (VRE)
	Background
	Policies
	Controversies (Table 3.1)
		Effectiveness of Universal Glove and Gown Use
		Cost-Effectiveness of Universal Glove and Gown
	Practical Resolutions
	Future Research
	Conclusions
	References
4: Isolation Precautions for Visitors to Healthcare Settings
	Introduction
	Visitors and Transmission/Outbreaks
	Visitors and Standard Precautions
	Hand Hygiene
	Visitors and Contact Precautions
	Visitors and Droplet Precautions
		Influenza
			Bordetella pertussis
	Visitors and Airborne Precautions
		Measles
	Immunocompromised Visitors
	Emerging Infections and Visitors to Healthcare Settings
	Ethical Considerations in Isolation Precautions for Visitors to Healthcare Facilities
	References
5: Bacterial Contamination of the Anesthesia Work Area: Hands, Patients, and Things
	MRSA and VRE
	Gram-Negative Organisms
	Intraoperative Anesthesia Work Area
		Environmental Contamination
		Hand Hygiene
		Increased Surgical Site Infections and Mortality
		Compliance with Cleaning and Disinfection
	Conclusions and Controversies
	References
6: Infection Control in the Outpatient Setting
	Introduction
	Definitions
		Applying the Principles of Hospital Infection Control to Outpatient Infection Control
	Infrastructure
	Standard Precautions
	Hand Hygiene
		Why Is Hand Hygiene Compliance So Poor in the Outpatient Setting?
	Recommendations
	Injection Practices
	Surveillance
	Regulations, Mandatory Reporting, and Monitoring
	Transmission-Based Precautions
	Respiratory Hygiene and Cough Etiquette
	Environmental Cleaning
	Medical Devices
	Antimicrobial Stewardship
	Medical Waste
	Education of Healthcare Personnel
	Risk Assessment
		Special Considerations
			Clostridium difficile in the Outpatient Setting
	Epidemic Keratoconjunctivitis
	Ambulatory Surgery Centers
	Dialysis Centers
	Conclusions
	References
7: New Technologies for Infection Prevention
	Introduction
	Ultraviolet (UV) and Hydrogen Peroxide (HP) Room Disinfection Systems
	Touchless Device Killing Efficacy
	Touchless Device Efficacy in Clinical Outcomes
	Outbreak Management
	Other Applications of Touchless Technology
	Challenges and Limitations of Touchless Devices
	Antimicrobial Surfaces
	Antimicrobial Fabrics
	Hand Hygiene Technologies
	Utility of Hand Hygiene Monitoring Systems
	Conclusion
	References
8: What Is the Role of Mobile No-Touch Disinfection Technology in Optimizing Healthcare Environmental Hygiene?
	Introduction
		No-Touch Disinfection Technologies
	Methods
		Hydrogen Peroxide No-Touch Systems
			Level I HP Studies: Laboratory Demonstration of Meaningful Pathogen Bioburden Reduction (In Vitro Studies)
			Level III HPV Studies: Demonstrate In-Use Pathogen Reduction of Clinical Relevance (In Situ Studies)
			Level IV HPV Studies: Demonstrate Reduced Pathogen Acquisition
			Level V HPV Studies: Demonstration of Reduced Infections
			Summary of Hydrogen Peroxide Vapor Disinfection Studies
		Ultraviolet No-Touch Systems
			Level I Studies: Laboratory Demonstration of Pathogen Bioburden (In Vitro Studies) Reduction
			Level III UV Studies: Objectively Demonstrate Clinical Relevance (In Situ Studies)
			Level V UV Studies: Demonstrate Decreased Infections
			Summary of UV Disinfection Studies
	Assessment of the Limitation of Published Clinical Studies
		Level III Studies
		Level IV and V Studies
	Conclusions
	Recommendations for Future Studies of Environmental Hygiene Interventions
	References
9: Universal MRSA/Staphylococcal Decolonization for Hospitalized Patients
	Introduction
	Nasal Topical Decolonization Strategies (Vertical)
	Chlorhexidene Bathing (Horizontal)
	Decolonization Prior to Surgery
	Universal Decolonization Versus Targeted Decolonization
	Conclusion
	References
10: Staphylococcal Decolonization in Surgery Patients
	Introduction
		Incidence and Sites of Colonization
		Type of Carriage
		Incidence of Surgical Site Infection (SSI), S. aureus SSI, and Association with Colonization
	Burden and Cost of Treating SSI
	Screening
	Methods of Decolonization
		Mupirocin
			Historic Controls
			Randomized Controlled Trials
			Mupirocin Resistance
		Povidone-Iodine
		Nasal Chlorhexidine
		Photodisinfection
		Perioperative Antibiotics
		Body Wash
	Timing of Decolonization
	Cost-Effectiveness of Decolonization
	MRSA Screening and Decolonization
	Conclusion and Summary of Recommendations
	References
11: The Surgical Care Improvement Project Redux: Should CMS Revive Process of Care Measures for Prevention of Surgical Site Infections?
	The Genesis of the Surgical Care Improvement Project
	Evidence to Support the SCIP Measures
		Perioperative Antimicrobial Prophylaxis
		Hair Removal Technique
		Perioperative Glucose Control
		Normothermia
	Did the SCIP Improve SSI Outcomes?
		Why Is It So Challenging to Demonstrate a Significant Impact on SSI Risk?
			Preoperative Skin Preparation Using a Long-­Acting Antiseptic Agent Plus Alcohol
			Administering Preoperative Oral Antimicrobial Prophylaxis to Patients Undergoing Colorectal Surgery
			Hemodynamic Goal-Directed Therapy
			Supplemental Oxygenation
			Preoperative Staphylococcus aureus Screening and Decolonization
			SSI Prevention Bundles
	Change of Focus from Process to Outcome Measures Used for Pay for Performance
	Limitations of SSI Outcome Measures for Pay for Performance
		SSI Surveillance Relies on Subjective Interpretation of Medical Information and Is Vulnerable to Gaming
		Surveillance Bias and Accessibility to Data
		Using SSI Outcomes to Judge the Performance of Hospitals Requires Adequate Risk Adjustment
		Outcome Measures Are Challenging to Apply to Small-Volume Hospitals
	Going Forward: Back to the Future?
	References
12: Healthcare Worker Apparel and Infection Prevention
	Healthcare Worker (HCW) Apparel and Infection Prevention
	Hospital Policies Regarding HCW Attire
	White Coats, Scrubs, and Uniforms
	Neckties
	Bare Below the Elbows (BBE) Strategy
	Laundering
	Outbreaks Related to HCW Apparel
	Innovations in Textiles
	Patients’ Perceptions Regarding HCW Attire
	Proposed Approach for HCW Attire
	References
13: Antimicrobial Textiles and Infection Prevention: Clothing and the Inanimate Environment
	Introduction
	Textiles in Healthcare
	The Role of Textiles in Hospital-Acquired Infections (HAIs)
	Antimicrobials in Textiles
		Triclosan
		Metallic Compounds
		Quaternary Ammonium Compounds
		Polybiguanides
		N-Halamines
	Test Methods for Assessing Antimicrobial Efficacy
	Evidence of Antimicrobial Activity in Hospital Textiles
		Bacterial Contamination of Antimicrobial-­Treated Textiles Compared to a Control
		Evidence of Antimicrobial-Treated Textile Effect on HAIs
	Conclusions
	References
14: Multidrug-Resistant Gram-Negative Bacilli: Infection Prevention Considerations
	Introduction
	Carbapenem-Resistant Enterobacteriaceae (CRE)
		Epidemiology and Microbiology
		Measures to Decrease CRE Patient-to-Patient Transmission
			Hand Hygiene
			Contact Isolation Precautions (CIP)
			Patient Cohorting and Dedicated Staff
			Environmental Cleaning and Disinfection
			Monitoring of Cleaning
			Shared Equipment
			Active Surveillance
			Decolonization for CRE
		Antimicrobial Stewardship
	Carbapenem-Resistant Pseudomonas aeruginosa
		Epidemiology and Microbiology
		Patient-to-Patient Transmission
			Hand Hygiene and Contact Isolation Precautions (CIP)
			Patient Cohorting and Dedicated Staff
			Environmental Cleaning and Disinfection
			Active Surveillance
			Decolonization for P. aeruginosa
		Antimicrobial Stewardship
	Acinetobacter Baumannii
		Epidemiology and Microbiology
		Measures to Decrease A. baumannii Patient-to-­Patient Transmission
			Patient-to-Patient Transmission Role and Hand Hygiene
			Contact Isolation Precautions (CIP)
			Patient Cohorting and Dedicated Staff
			Environmental Cleaning and Disinfection
			Active Surveillance
			Decolonization for A. baumannii
		Antimicrobial Stewardship
	ESBL- and/or AmpC-Producing Enterobacteriaceae
		Epidemiology and Microbiology
		Measures to Decrease Patient-to-Patient Transmission of ESBLs and AmpCs
			Hand Hygiene
			Contact Isolation Precautions (CIP)
			Patient Cohorting and Dedicated Staff
			Environmental Cleaning and Disinfection
			Active Surveillance
			Decolonization for ESBLs and AmpCs
		Antimicrobial Stewardship
	References
15: Active Surveillance Cultures for MRSA, VRE, Multidrug-Resistant Gram-­Negatives
	Introduction and Definition
	Evidence to Support or Refute Active Surveillance
	MRSA
	VRE
	Sites and Method of Surveillance
	VRE
	MDR-GN
	Patient Populations to Screen, Frequency of Screening, and Duration of Colonization
	Conclusions
	References
16: C. difficile Microbiome Manipulation
	Introduction
	Clostridium difficile
	Intestinal Microbiome
	Microbiome and C. difficile
	Studies of Microbiome Manipulation and C. difficile
	Probiotics
	Probiotics for Primary Prevention of C. difficile
	Guidelines for Use of Probiotics for Primary C. difficile Prevention
	Probiotics for Secondary Prevention of C. difficile
	Guidelines for Use of Probiotics for Secondary C. difficile Prevention
	Probiotics as Adjunctive Therapy for C. difficile
	Probiotic Mechanisms
	Fecal Microbiota Transplantation for C. difficile
	FMT for Immunocompromised Patients
	FMT Mechanisms
	Guidelines for Use of FMT in CDI
	Purified Culture as Treatment for or for Prevention of C. difficile
	Conclusions
	References
17: Air Contamination in the Hospital Environment
	Introduction
	General Principles
	Indications for Sampling Air in the Hospital Setting
	Air Sampling Methods
		Passive Methods for Sampling Air
		Active Methods for Sampling Air
	Gram-Positive Organisms
	Methicillin-Resistant Staphylococcus aureus
	Vancomycin-Resistant Enterococci
		Clostridium difficile
	Gram-Negative Organisms
		Acinetobacter baumannii
		Pseudomonas aeruginosa
	Klebsiella-Producing Carbapenemase (KPC)-Producing Gram-Negative Rods
	Conclusions
	References
18: Vertical Versus Horizontal Infection Control Interventions
	Vertical Versus Horizontal Infection Control Interventions
	Compare and Contrast Vertical and Horizontal Strategies
	Evidence for Vertical Infection Control Strategies
	Methicillin-Resistant Staphylococcus aureus
	Carbapenem-Resistant Enterobacteriaceae and Acinetobacter baumannii
	Vancomycin-Resistant Enterococcus
	Evidence for Horizontal Infection Control Strategies
		Hand Hygiene
	Universal Decolonization
	Selective Digestive Tract Decolonization
	Antimicrobial Stewardship
	Environmental Cleaning
		Financial Considerations
	Conclusion
	References
19: The Role of the Hospital Epidemiologist
	Background
	Training
	Duties of the Healthcare Epidemiologist
		Administration
		Surveillance
		Outbreak Investigation
		Public Health/Emergency Preparedness
		Education
		Employee Health
		Quality Improvement and Patient Safety
		Antimicrobial Stewardship
		Research
	Resources and Compensation
	Conclusions
	References
20: Whole Genome Sequencing for Outbreak Investigation
	Introduction
	Overview of Whole Genome Sequencing and Older Typing Methods
		Next-Generation Sequencing
		“Third-Generation” Sequencing
		Older Bacterial Typing Methods
		Comparison of Whole Genome Sequencing with Older Methods
		Sequence Analysis
	Use of Whole Genome Sequencing for Outbreak Investigation
		International Outbreak Investigation
		Hospital Outbreak Investigation
		Real-Time Whole Genome Sequencing During a Nosocomial Outbreak
		Plasmid Sequencing to Identify Horizontal Transmission of Resistance Genes
		Sequencing of Endemic-Multidrug-Resistant Organisms
		Interinstitutional Outbreak Investigation
		Molecular Clocks and the Dynamics of Sampling
	Whole Genome Sequencing to Elucidate Mycobacterial Transmission
		Whole Genome Sequencing for Foodborne Outbreaks
		How Can Whole Genome Sequencing Generate Actionable Data?
	Bioinformatics Expertise
	Conclusion
	References
21: Viral Hemorrhagic Fever Preparedness
	Introduction
	History of Biocontainment
	Background: Viral Hemorrhagic Fever (VHF)
	Facility Design
	Administration and Support Services
	Staffing: Nursing
	Staffing: Physicians
	Personal Protective Equipment (PPE)
	Transportation
	Clinical Care
		Laboratory Support
	Waste Management
	Care of the Deceased
	Evaluation of Persons Under Investigation (PUI)
	Special Populations
	Maintenance of Preparedness
	Conclusions and Future Directions
	References
22: Probiotics and Infection Prevention
	Introduction
	VRE Colonization
	Prevention of Multidrug-Resistant Organisms
	Risks of Hospital-Acquired Infection Due to Use of Probiotics
	Conclusion
	References
23: Animals in Healthcare Settings
	Introduction
	Background
	Risks of Animals in Healthcare
	Benefits of Animal-Assisted Therapy
		Background
		Benefits/Risks
		Mitigation
		Future Research Needs
		Conclusions
	ADA: Role of Animals Used for Emotional Support as “Service Animals”
		Background
		Benefits/Risks
		Mitigation
		Future Research Needs
		Conclusions
	Cats
		Background
		Benefits/Risks
		Mitigation
		Future Research Needs
		Conclusions
	Research Animals
		Background
		Benefits/Risks
		Mitigation
		Conclusions and Future Research Needs
	Pets
		Background
		Benefits/Risks
		Mitigation
		Future Research Needs
		Conclusions
	Medicinal Leeches
		Background
		Benefits/Risks
		Mitigation
		Future Research Needs
	Maggot Debridement Therapy
		Background
		Benefits/Risks
		Mitigation
		Future Research Needs
	Aquariums/Fish Tanks
		Background
		Benefits/Risks
		Mitigation
		Future Research Needs
	Petting Zoos
		Background
		Mitigation
		Future Research Needs
	Conclusions
	References
24: Decolonization in Infection Control of Gram-Negative Bacilli
	Background
	Skin Decolonization for Gram-Negative Bacilli Infections
	Chlorhexidine Gluconate
	Selective Decontamination
	Systemic Antibiotics
	Investigational Agents for Decolonization
	Fecal Microbiota Transplantation
	Probiotics
	Conclusions
	References
25: Testing Water for Legionella Prevention
	How to Test for Legionella
		Culturing Methods
		Legionella Growth Requirements
		Legionella Burdens Within Positive Water Cultures
		Amoeba Culture
		Additional Detection Methods
	Which Water to Test
	When to Test
		Case Investigation
		Surveillance
	What to Do with Surveillance Results
	Controversies
	Conclusions and Perspectives
	References
26: The Importance of C. difficile Colonization in Infection Prevention
	Prevalence of and Risk Factors for Asymptomatic Colonization with  C. difficile
	Detection of C. difficile Carriers and Its Impact on CDI Rates
	Association of C. difficile Colonization with Subsequent Symptomatic CDI
	Contribution of Asymptomatically Colonized Patients to In-Hospital CDI Transmission
	HCW and Environmental Contamination Related to Asymptomatically Colonized Patients
	Impact of Strain Type on the Role of Asymptomatic Colonization
	Effect of Targeting Asymptomatically Colonized Patients for Infection Prevention Interventions
		Contact Precautions and Active Surveillance
		Treatment of C. difficile Asymptomatic Carriers
	References
27: Mandatory Influenza Vaccination of Healthcare Personnel
	Introduction
	History of Mandatory Influenza Vaccination for HCP
	“Healthcare-Associated Influenza Is Not a Problem”
	“Influenza Is Not a Major Problem Among HCP”
	“Mandatory Programs Have Never Been Shown to Impact Healthcare-Associated Influenza”
	“The Influenza Vaccine Is Not Efficacious Enough to Warrant a Mandate”
	“Influenza Vaccine Safety Is Still a Concern”
	“There’s No Risk for Influenza Transmission from Asymptomatic HCP”
	“Masking Unvaccinated HCP Is Punitive and Not Evidenced Based”
	Conclusions
	References
28: Controversies in Healthcare-Associated Infection Surveillance
	Variability and Subjectivity in HAI Surveillance
	HAI Surveillance Is Resource Intensive
	HAI Surveillance Is Not Clinically Meaningful
	Other Threats to Validity of HAI Surveillance Metrics: Choice of Denominator and Risk Adjustment
	Use of Administrative Data Approaches
	Algorithmic Approach to HAI Surveillance
	Objective Lab ID Approaches
	Clinically Meaningful Measures for HAI Surveillance
	Conclusion
	References
29: Chlorhexidine Gluconate Bathing Outside the Intensive Care Unit
	Introduction
		Hospitalized Patients
			Hospital Wards
			Long-Term Care Facilities
			Preoperative Use
		Outpatients
	Outpatient Clinics
	Military
	Correctional Facilities
	Athletes: Amateur and Professional
	Challenges
	Adherence and Technique
	Avoidance of Incompatible Products
	Concerns with CHG Resistance
	Conclusion
	References
30: Airborne Precautions and Personal Protective Equipment: The Powered Air-Purifying Respirator-Only Approach
	Airborne Isolation Precautions and Personal Protective Equipment
		Physical Space and Engineering Controls
		Personal Protective Equipment and Healthcare Personnel Respiratory Protection
			Pros and Cons of PAPRs
			Pros and Cons of N95 Respirators
		Clinical Protocols, Policies, and Procedures
		Regulatory Standards
	PAPR-Only Approach?
		Implementation Approaches in Different Hospitals and Health Systems
			PPE Choice and Safety
			Maintenance of PAPR
			Indications for Use
			Cost-Effectiveness for Routine Clinical Care and Pandemic Preparedness
			PAPR Design
		When Would PAPR-Only Approach Work?
	References
31: Donning and Doffing of Personal Protective Equipment (PPE): Is Training Necessary?
	Introduction
	Self-Contamination
	Types of Training and PPE
	Training for Reduction of Self-Contamination in the Acute Care Hospital
	Limitations of the Available Data
	Conclusion
	References
32: Rapid Diagnostics in Infection Prevention
	Introduction
	Carbapenem-Resistant Enterobacteriaceae
	Methicillin-Resistant Staphylococcus aureus
	Vancomycin-Resistant Enterococcus spp.
	Clostridium difficile
	Conclusion
	References
Index