Infections - TBRHSC

Sexual contact with an infected partner.
Sharing of needles and sometimes deep or blood- contaminated needlesticks or other sharps injuries.
Transfer from mother to baby pre or perinatally HIV is transmitted in blood and in bloody body fluids.
It is not transmitted in saliva, urine, feces, tears, sweat or other non-bloody body fluids.
In order for HIV to infect an individual it must come into contact with their blood, through a needle or cut, or it must come in contact with mucous membranes (such as during sexual contact).

Which patients are at high risk?

Anyone with certain high risk behaviours can have HIV. HIV now affects both heterosexual and homosexual men and women and babies of HIV positive moms.

The high risk groups for HIV are:

men who have sex with men
persons who have used illegal drugs by injection
persons who have had a blood transfusion or received blood products or organs between 1978 and 1985
persons who come from areas of the world in which HIV is endemic
persons who have had a sexual partner from any of the above groups
infants born to HIV-infected women.

What precautions should be taken with HIV positive patients?

There is no need for any special precautions with HIV positive individuals. Regular Body Substance Precautions and safe handling and disposal of sharps should be used with all individuals regardless of diagnosis.

REMEMBER, BODY SUBSTANCE PRECAUTIONS MUST BE TAKEN WITH ALL BLOOD AND ALL BODY FLUIDS FROM ALL PATIENTS

CLOSTRIDIUM DIFFICILE

What is it?

Clostridium difficile (often shortened to c. diff.) is a bacteria that causes antibiotic-associated pseudomembranous colitis. C diff. forms a “spore” which is relatively resistant to disinfectants.

Who is at risk?

Patients who use antibiotics such as penicillins, cephalosporins and clindamycin have about a 40% chance of becoming colonized with C. difficile. There are increasing reports of c. diff. outbreaks in hospitals, caused by spread of this bacteria from patient to patient on unwashed hands or on environmental surfaces and equipment that are contaminated with feces (commodes, toilets, rectal thermometers, for example).

Why is it a problem?

C. difficile is a problem in hospitals because it can cause significant morbidity and, in some cases, mortality. Outbreaks of c. diff are occuring hospitals and can be difficult to control.

How is the spread of C. Difficle Controlled?

C. diff. is spread by person-to-person transmission and through contact with items that are contaminated with feces. A special cleaning procedure is used by housekeeping at patient discharge and/or when the patient becomes asymptomatic. Good handwashing and appropriate use of gloves when handling the patient or items that are contaminated with feces (as per usual Body Substance Precautions) can limit spread. Patients who are positive for c. diff and have diarrhea are placed into “Contact Precautions” with a green stop sign on the door. Precautions include: private room with separate toilet facilities, gown and gloves for contact with patient and items in the room and cohorting of commodes and other items that may become fecally contaminated. Precautions are discontinued once the patient is asymptomatic (no diarrhea) for over 48 hours. There is no need to retest unless that patient develops symptoms again. There is at least a 20% chance of reoccurence of c. diff..

Can it be treated?

It may be necessary to discontinue any antibiotics, and this alone may be successful Flagyl (oral metronidazole) may also be used to treat it or, as a last resort, oral Vancomycin.

EXTENDED SPECTRUM BETA-LACTMASES (ESBLs)

Introduction

The problem of ever increasing antimicrobial resistance has been well reported in journals and the lay media. In addition to the terms “MRSA” and “VRE”, a new type of antibacterial resistance has emerged, largely as a consequence to the overuse of antibiotics. These have been coined the term extended spectrum beta-lactamases or ESBL. ESBLs were first identified in the early 1980s, when cefotaxime (a broad spectrum antibiotic)-resistant strains of Klebsiella pneumoniae and Escherichia coli were isolated from patient specimens in Germany and France.

The Problem

Normally, gram-negative organisms such as Klebsiella pneumoniae and Escherichia coli are very susceptible to broad spectrum antibiotics such as cefotaxime (Claforan) or ceftriaxone (Rocephin). Mutations in these specific enzymes have resulted in resistance to this class of drugs known as third generation cephalosporins. To date, over 26 ESBLs have been identified. The problem occurs in trying to treat infections caused by ESBLs. Typically, ESBLs will enable resistance to many other classes of antibiotics. In addition, which antibiotic the organism is sensitive to is dependent upon the particular organism and the particular type of ESBL produced.

Infection Control

At present, there is little concrete literature on infection control for this organism. Hospitals in the Toronto area have seen this bacteria with increasing frequency. There are some facts which are certain. As with other gram-negative organisms, the mode of transmission of ESBLs is through contact with the patient or their immediate care environment which may be contaminated with these bacteria. However, the main mode of transmission is unwashed hands of care providers. Contact precautions (green stop sign) private room, gown, gloves and handwashing for all who enter the patients room. To determine if there has been transmission to other patients, urine specimens and swabs from draining skin sites and rectal area are obtained from roommates of the positive patient. If this organism is detected in other patients they will also be placed in a private room with contact precautions.

What is the risk to patients?

The concern with ESBLs, as with VRE and MRSA, is that these bacteria can spread to the more acute, immunocompromised patients and cause an infection which may be more difficult to treat due to reduced choice of suitable antibiotics. ESBL-producing Eschericia colii and Klebsiella pneumoniae are no more pathogenic or capable of causing disease than susceptible forms of these bacteria. December 1998.

GROUP A STREP (GAS) FACTS

What is it?

Group A Strep ( or Strep Pyogenes) is a member of the bacteria family Streptococci. It can cause symptoms and illnesses such as: upper respiratory tract infections, minor skin infections, scarlet fever, erysipelas and in some cases, toxic shock syndrome and necrotizing fascitis (flesh-eating disease). Both toxic shock syndrome and necrotizing fascitis are serious and often life-threatening infections. Any Group A strep isolated from a normally sterile body site or from patients with toxic shock syndrome or necrotizing fascitis are reportable to the Public Health Department.

How is it spread?

It is usually spread through mucous membrane contact with infected persons or carriers. It can be spread through large droplets. Staff who are anal, vaginal, skin or pharyngeal carriers have been responsible for outbreaks of serious Group A Strep infections in hospitals.

Which patients are at risk?

Patients who are in direct contact with staff or other caregivers who have Group A strep infections or are carriers. Once a person has been on effective antibiotic treatment for over 24 hours they are considered no longer infectious.

Should patients with Group A Strep be isolated?

Patients with Invasive Group A strep (toxic shock syndrome, necrotizing fasciitis) are placed in Contact Precautions (green stop sign) with private room, and gloves and gowns for all contacts.

GOOD HANDWASHING AND BODY SUBSTANCE PRECAUTIONS FOR ACTUAL OR POTENTIAL CONTACT WITH SALIVA OR ITEMS CONTAMINATED WITH SALIVA ARE ESSENTIAL AT ALL TIMES (FOR ALL PATIENTS).

How is it treated?

There are antibiotics which can be ordered by the physician. In addition there is evidence that IVIG (intravenous immune globulin) is effective in treatment of Invasive Group A strep diseases. revised: May 1999

HEPATITIS B, C, and D FACTS

What is it?

Hepatitis B, C and D viruses cause inflammation of the liver. NOTE: A blood test showing positive HBSaG indicates current active Hepatitis B. A test showing positive anti-HBs alone indicates that the person has immunity to Hepatitis B. Anti-HCV indicates either current or previous exposure to Hepatitis C.

How is it spread?

Hepatitis B is spread by blood or mucous membrane contact with an infected person's blood, saliva, semen or vaginal fluids. Blood transfusions, sharing needles, acupuncture, tatooing and needlesticks/sharps injuries also can transmit Hepatitis B. Sexual contact and mother to baby are other ways Hepatitis B is spread. Hepatitis C is spread through blood or mucous membrane exposure to infected blood or blood products. Hepatitis D is found only in the presence of Hepatitis B. It is spread the same way as Hepatitis B.

Which patients are at risk?

For Hepatitis B and D: patients who have had blood transfusions, shared needles or had sexual contact with infected individuals or born to a Hepatitis B positive mother. For Hepatitis C: patients who have had blood transfusions.

SHOULD PATIENTS WITH HEPATITIS B, C OR D BE ISOLATED?

NO! THERE IS NO NEED TO TAKE SPECIAL PRECAUTIONS FOR PATIENTS WITH HEPATITIS B, C OR D. WHEN USING BODY SUBSTANCE PRECAUTIONS, ALL BLOOD AND BODY FLUIDS ARE HANDLED THE SAME FOR ALL PATIENTS.

HOW CAN THE TRANSMISSION OF HEPATITIS B, C AND D BE PREVENTED?

Safe handling of sharps and Body Substance Precautions can prevent exposures to blood and body fluids. For Hepatitis B a vaccine can be given to persons at risk of contracting Hepatitis B (ie patient care workers who come into contact with blood or bloody body fluids). Prophylaxis is available for high risk exposures to blood or bloody body fluids, for non-immunized and\or non- immune persons. There is no treatment or vaccine for Hepatitis C or D.

METHICILLIN-RESISTANT STAPH AURUS (MRSA)

What is it?

MRSA (Methicillin-resistant staph aureus) is a form of a bacteria called "staph aureus" which has become "resistant" to a number of antibiotics. Many persons have "regular" staph aureus living on their skin, minor skin sores or in their noses. MRSA is no more virulent or capable of causing infection than regular staph aureus.

How is it spread?

MRSA is spread by direct contact with infected or colonized patients. It is not spread through the air and not usually spread through items such as floors, walls or furniture.MRSA can also be spread by staff who are nasally colonized with MRSA (1-3% of staff during outbreaks of MRSA).

How is transmission of M.R.S.A. controlled?

Patients colonized or infected with MRSA are placed in a private room in Contact Precautions (green stop sign). Precautions include: gowns, gloves, handwashing for all contacts with patient or items in their room. When a case of MRSA is found the roommate(s)or other close patient contacts are cultured nasally and rectally for MRSA If the roommates\close contacts are positive then other patients on the unit may be cultured. During outbreaks, or when transmission is suspected, direct care staff may be tested (nasal swabs) All persons must wash their hands, upon leaving the patient room; as this bacteria is most often spread by unwashed hands.

HOW IS M.R.S.A. TREATED?

Bactroban ointment can eradicate MRSA colonization from nares or other skin sites. There are a few antibiotics, prescribed by the doctor, which can be used to treat MRSA. infections. After treatment with antibiotics, patients are retested to see if the MRSA is still present. Once negative for 3 weeks precautions are discontinued. revised: May 1999

SCABIES FACT SHEET

What is it?

Scabies is a contagious skin disease characterized by persistent itching and red flaky small mounds or patchy rash . The rash usually appears in axilla, groins, under breasts, at waistline, inside of elbows and wrists and at any other skin creases.

How is it spread?

Scabies is spread through direct contact with infested patients or others or with items that have come in close contact with that person (clothing, bedding for instance) Scabies may take 4 - 6 weeks to occur after contact.

SCABIES DO NOT JUMP FROM PERSON TO PERSON...NOR DO THEY FLY...SCABIES IS SPREAD BY DIRECT CONTACT AS ABOVE.

How is it treated?

A special cream (NIX) is available. NIX is applied and left on for 12 - 14 hours then once again a week later. All bedding and clothing should be laundered thoroughly after the treatment. After 1 treatment the person treated is usually non-contagious. Any item that cannot be washed should be placed in a plastic bag for at least 72 hours ( the scabies mites do not live very long when off the human body). Pregnant or lactating women should speak with their doctor before treatment.

How long are precautions necessary?

Precautions are needed for at least 12 - 14 hours after application of treatment cream. For patients with scabies, gloves and gowns should be used for direct patient contact or during contact with bedding or clothing. Itchiness may persist for a long time, even after successful treatment.

TB (TUBERCULOSIS)

What is it?

Tuberculosis (TB) is caused by a group of mycobacteria called "Mycobacterium tuberculosis". TB most often occurs in the respiratory tract. TB that occurs outside of the respiratory tract is unlikely to be transmitted to others.

How is it spread?

TB (pulmonary) is spread by the respiratory or droplet route, in other words, by inhaling of airborne particles of TB which are exhaled from the infected person by coughing, talking or sneezing or during cough-inducing procedures. Prolonged, close contact with the infected person, increases the likelihood of transmission.

Which patients are at high risk?

High risk individuals for TB are those who:

have a chest xray suggestive of active TB
have an AFB (acid fast bacilli) positive sputum smear
are Aboriginal Canadians, persons born in countries with high TB rates, poor and homeless persons, elderly (especially single men), substance abusers, or persons with HIV
have two or more of the following symptoms: chronic cough (over 4 weeks), fever (longer than 1 week) or weight loss.

From Health Canada 1996.

Which patients should be isolated?

A definitive positive of Mycobacterium TB now takes 5 - 7 days, therefore, isolation precautions must be taken for all persons who are at high risk for TB according to the above criteria. A private room with door closed and "stop sign" is required and all persons entering room must wear a "Tecnol Fluid Shield mask". Gown and gloves are not necessary. If patient leaves room for any reason they must wear a surgical mask.

NOTIFY INFECTION CONTROL COORDINATOR WHEN PRECAUTIONS INITIATED OR IF THERE ARE CONCERNS ABOUT PATIENT RISK FACTORS.

How long should isolation be in place?

Isolation precautions of AFB positive patients are discontinued only when: consecutive sputum smears are negative for AFB on 3 separate days AND there is evidence of clinical improvement, AND there is reasonable evidence of adherence to the medication regime or a minimum of 2 weeks. For previously AFB negative patients, discontinue isolation after 2 weeks of therapy. Routine cleaning of room takes place when isolation stopped or patient discharged. TB is not spread on environmental objects.

What happens when the high risk or known positive person has not been isolated appropriately?

All "unprotected" exposures (ie. no precautions taken) of staff must be reported to the Occupational Health Nurse to ensure follow-up. Exposure of patients or others must be reported to the Infection Control Coordinator, who will, along with Public Health Unit, ensure other patients and other exposed individuals are tracked and follow-up undertaken.

What happens if the patient is non-compiant with isolation precautions or treatment?

Under the Health Protection and Promotion Act, mTB is a reportable disease and the person is required to comply with measures to prevent the spread of the disease and also to take their prescribed treatment. Non- compliance should be reported to the physician and to the Public Health Unit.

Skin Testing

A positive TB skin test does not indicate that the person has active TB! (See high risk patient above). A positive TB skin test is 10 or more millimeters of induration (not just redness) at 48 - 72 hours after test. In some cases a skin test of 5 to 10 mm. is considered positive if: the person is a recent close contact of an individual with infectious TB, or the person has a chest x-ray with findings suggestive of old healed TB or the person is known or suspected to have HIV or is immunocompromised for other reasons.

A two-step skin test is recommended for the elderly and immune-compromised.

Treatment

For patients with known or suspect TB the physician usually orders a combination of 3 or more TB drugs. July 1997

VRE (VANCOMYCIN-RESISTANT ENTEROCOCCI) FACTS

What is it?

VRE is a bacteria (enterococci) that has become resistant to all currently approved antibiotics including Vancomycin. Enterococci can cause infections if they get into the lungs, blood or bladder or other body sites. VRE infections are serious because there are no current approved antibiotics available for VRE. There are experimental drugs available). Many patients, fortunately, are only colonized with VRE (ie. it is living harmlessly on them). However, these patients are a reservoir for this bacteria and may spread it to other patients.

How is it spread?

VRE spreads very easily in the hospital environment and can lead to major outbreaks if uncontrolled. It can be spread on the hands of caregivers, on patient care equipment and on environmental surfaces. Patients with VRE (infection or colonization) who soil their environment with diarrhea or wound drainage are especially likely to spread VRE. VRE is not airborne.

Which patients are at risk?

Any patient who is a roommate or in an adjacent or nearby room of a VRE positive patient is at risk. Patients on high risk units such as Oncology, ICU, NICU, Renal dialysis are especially at risk if VRE is uncontrolled in a hospital setting. Any patient who has been hospitalized overnight in any hospital or long term care facility may have VRE. VRE does not pose a threat to staff.

What precautions should be taken with VRE positive patients?

As a preventative measure, all patients are screened at admission, and for high risk patients (see above) a rectal swab is obtained for VRE (along with a rectal and nasal swab for MRSA). If any patient is found to be VRE positive, or was hospitalized outside Canada, the patient is immediately placed into a private room with special contact precautions (Pink stop sign): gown, gloves, handwashing, cohorted patient care supplies and special cleaning).

How should patient contacts be managed?

When a VRE positive patient is found, patients on the unit, or on other units, will be tested for VRE as directed by Infection Control Coordinator. Revised: May 1999