Healthcare-Associated Infections and Infection Control by xmOb05NH

VIEWS: 60 PAGES: 53

									Healthcare-Associated Infections
      and Infection Control

         Timothy H. Dellit, MD
    Medical Director, Infection Control
      Harborview Medical Center
Patient Safety and Infection Control
• Prevention, monitoring, and feedback
  – Healthcare-associated infections
     •   Catheter-associated bloodstream infections
     •   Ventilator-associated pneumonia
     •   Surgical site infections
     •   Catheter-associated UTI
  – Transmission of multidrug-resistant/marker organisms
     •   MRSA
     •   VRE
     •   Carbapenem-resistant Acinetobacter
     •   ESBL-producing organisms → MDR Enterobacteriaceae
     •   C. difficile
     •   Aspergillus in burn and immunocompromised populations
     •   Tuberculosis
   Increasing Regulation and Reporting
                                                       CMS RHQDAPU
• CMS and “preventable events”                         FY2013-FY2015
   – FY2008                                            CLA-BSI
       • Catheter-associated urinary tract infection   SSI
       • Vascular catheter-associated infections       CA-UTI
       • Mediastinitis after CABG                      Central line bundle compliance
   – FY2009                                            MRSA bacteremia
       • SSI following select orthopedic procedures    C. difficile
            – Spinal fusion                            Influenza vaccination of HCW
            – Elbow and shoulder arthroplasty
       • SSI following bariatric surgery
• Mandatory reporting of healthcare-associated infections (HB 1106)
   – Central line infections in ICU: July 2008
   – Ventilator-associated pneumonia: January 2009
   – Selected surgical site infections: January 2010
       • Cardiac surgery
       • Total hip and knee arthroplasty
       • Hysterectomy
                     “MDRO Bundle”
•   Hand Hygiene                                                   Increased Hand Hygiene Associated with
•   Contact precautions                                                 Decreased MRSA Transmission
•   Minimize shared equipment                                100                                                 2.5

•   Environmental cleaning                                   90                         Hand hygiene




                                                                                                                       Transmission per 10,000 patient-days
•   Healthcare-associated                                    80                         MRSA Transmission rate   2




                                    Hand Hygiene Adherance
    infections preventive bundles                            70

     – Catheter-associated BSI                               60                                                  1.5

     – Ventilator-associated                                 50
       pneumonia                                             40                                                  1
     – Catheter-associated UTI                               30
     – SCIP measures                                         20                                                  0.5
• Active surveillance cultures                               10
• Chlorhexidine baths                                         0                                                  0
• Antimicrobial stewardship                                              1994                   1998


• Patient and staff education                                         Lancet 2000;356:1307-12
  Role of Environmental Contamination
       Bed Linen
                                                                     Contact Contamination
     Patient Gown                                             100
                                                              90        Contact with patient
    Overbed Table                                             80
                                                                        Contact with environment




                                           Percent positive
                                                              70
         BP Cuff
                                                              60

        Side Rails                                            50
                                                              40
 Bath Door Handle                                             30
                                                              20
  IV Pump Button                                              10
                                                               0
Room Door Handle                                                       Gowns             Gloves



                     0     20        40                         60         80           100

                          Percent of Surfaces Positive for MRSA

   Infect Control Hosp Epidemiol 1997;18:622-627
          Who are you sleeping with?




40% increased risk of transmission
associated with prior occupant’s
MRSA or VRE carriage

Arch Intern Med 2006;166:1945-1951   Infect Control Hosp Epidemiol
                                     2011;32:201-6
          To Survey or Not to Survey?
                                                                   Surveillance Cultures Reduce MRSA Bacteremia




                                    Incidence density per 1000 pt-days
                                                                          5         No Surveillance
•   Interventions over 9 yr                                              4.5        Active Surveillance
     – Sterile CVC placement                                              4
     – Alcohol-based hand
                                                                         3.5
       hygiene
                                                                          3
     – Hand hygiene campaign                                                             75%                               67%
     – ICU surveillance for                                              2.5
       MRSA (16 months)                                                   2
•   29% of newly detected                                                1.5
                                                                                                          40%
    MRSA carriers develop                                                 1
    infection within 18 months                                           0.5
                                                                          0
                                                                                  ICU               Non-ICU     Hospital



                                                                               Reduced ICU transmission by 47%
    Clin Infect Dis 2003;36:281-5                                              • 43 vs. 23 cases per 1000 at risk patients
    Clin Infect Dis 2006;43:971-8
                     VA MRSA Initiative

• Decreased transmission

• Reduced HAIs
    • MRSA VAP
    • MRSA CLA-BSI
    • C. difficile in non-
    ICU
    • VRE in ICU and
    non-ICU




                               N Engl J Med 2011;364:1419-30
          Active Surveillance and
         Contact Precautions in ICU
          • Cluster randomized study in 18 ICUs
          • Surveillance cultures for MRSA and VRE
                - Mean delay in results 5.2 days


                                        Control        Intervention
MRSA or VRE colonization or               35.6             40.4
infeciton (rate per 1000 pt-days)
Days in Contact Precautions (%)           38%              51%
Hand hygiene                              59%              69%
Gloves                                    72%              82%
Gowns                                     59%              77%


                                    N Engl J Med 2011;364:1407-18
          Daily Chlorhexidine Baths




                      Baseline        CHG Baths           P
MRSA acquisition*      5.04              3.44           0.046
VRE acquisition*       4.35              2.19           0.008
VRE bacteremia*        2.13              0.59          0.0006
  *per 1000 pt-days              Crit Care Med 2009;37:1858-1865
Chlorhexidine baths in Trauma ICU


• Before and after introduction of daily
CHG baths in TICU
• In pre-contact precaution era
• Reduction in CR-BSI from 8.4 to 2.1
per 1000 catheter-days (P=0.01)
• Reduction in MRSA VAP from 5.7 to
1.6 per 1000 vent-days (P=0.03)



                                           Arch Surg 2010;145:240-246
                                                    HMC Nosocomial MRSA Rates
                                        20                                                                                                 100
                                                                        Quarterly                      Number of Cases
         Rate Per 1,000 Admissions ..
                                                                                                       2007: 331 Cases
                                        16                                                             2008: 268 Cases                     80
                                                                                                       2009: 154 Cases
                                                                                                       2010: 142 Cases




                                                                                                                                                 MRSA Cases
                                        12                                                                                                 60

                                                                                                        0.9 per 1000 pt-days

                                         8                                                                                                 40



                                         4                                                                                                 20



                                         0    QE QE QE QE QE QE QE QE QE QE QE QE QE QE QE QE QE
                                                                                                                                           0
                                              Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar
                                             2007 2007 2007 2007 2008 2008 2008 2008 2009 2009 2009 2009 2010 2010 2010 2010 2011
Nosoc MRSA Cases                              87   84   88   72   71   62   72   63   46   40    27    41    30    36    39    37    29
Admits                                       4,4894,8044,8544,5104,5434,6844,8644,6184,8635,0775,1354,8234,7604,8615,2854,9464,668
MRSA Rate                                    19.4 17.5 18.1 16.0 15.6 13.2 14.8 13.6 9.5   7.9   5.3   8.5   6.3   7.4   7.4   7.5   6.2

  Source: Infection Control, for more information, please contact Dr. Tim Dellit, thdellit@u.washington.edu                    Confidential QI
Which of the following bundle elements is
NOT correct?

A. VAP and head of bed > 30 degrees
B. VAP and sedation awakening
C. VAP and DVT prophylaxis
D. Central line and maximum barriers including full
body drape, sterile gown, sterile gloves, mask with
eye protection, and haircover
E. Central line and povidone-iodine skin prep
F. Central line and hand hygiene
       Central Line-Associated BSI

• ICU CVC utilization 0.39 – 0.71 catheters/pt
   – 15 million catheter-days per year in US
• ICU rate 1.2 to 5.3 per 1000 catheter-days (NHSN mean)
   – 80,000 CR-BSI annually in US ICUs
   – Attributable mortality 0-35%
• Healthcare cost $296 million to $2.3 billion
   – Attributable cost $15,000-$56,000
   – Prolonged ICU and hospital LOS




Clin Infect Dis 2002;35:1281-307
National healthcare Safety Network (HNSN) Report, Data Summary for 2009
           NHSN CLA-BSI Pathogens
                                   1986-1989     1992-1999    2006-2007
 Pathogen                            (%)              (%)        (%)
 Coag-negative staphylococci          27               37        34
 Staphylococcus aureus                16               13        10*
 Enterococcus                          8               13        16
 Candida sp.                           8                8        12
 Enterobacter                          5                5         4
 Pseudomonas aeruginosa                4                4         3
 Klebsiella pneumoniae                 4                3         5
 E. Coli                                6              2          3



Clin Infect Dis 2002;35:1281-307                  *MRSA 5.6%, MSSA 4.3%
Infect Control Hosp Epidemiol 2008;29:996-1011
Prevention of Catheter-Associated BSI

• IHI “Central Line Bundle”
  – Hand hygiene
  – Chlorhexidine skin prep
  – Maximal barriers
     • Full drape
     • Mask, hair cover, sterile gown, sterile gloves
  – Optimal catheter site selection
  – Daily review of line necessity
• Implementation AND documentation
          Institute for Healthcare Improvement
                                                 Bundle in Action
                                3.0
Median Bloodstream Infections




                                                                            Overall
                                2.5                                         Teaching Hospital
  per 1000 Catheter-Days




                                                                            Non-teaching Hospital
                                                                            < 200 beds
                                2.0
                                                                            > 200 beds


                                1.5



                                1.0



                                0.5



                                0.0
                                      Baseline    0-3      4-6     7-9     10-12      13-15         16-18

                                                        Months After Implementation
                                Reduction in mean rate from 7.7 to 1.4 per 1000 catheter-days
                                                                     N Engl J Med 2006;355:2725-32
UHC Benchmark of Key Performance Measures

               Key Performance Measure                             Hospital Performance
                                                                           % of cases
                     Patient Level
                                                                  median          range
Central Venous Catheter Placed in the Subclavian Vein              44.2%        14.3 – 73.3%
Evidence of Maximal Barrier Precautions for Insertion               0.0%         0.0 – 8.2%
                                                 Hand Washing       0.0%        0.0 – 39.0%
                                                Full Body Drape     3.0%        0.0 – 46.3%
                                        Sterile Gloves and Gown     1.9%        0.0 – 39.0%
                                                 Cap and Mask       0.0%        0.0 – 13.6%
Chlorhexidine Skin Prep for Insertion                               1.9%        0.0 – 98.1%
Daily Dressing Inspection                                          97.5%        25.1 – 100%
Daily Assessment of Medical Necessity to Continue CVC              16.4%        0.0 – 100%
                         Operational                              Yes % (n)        Site #
Best Practice* CVC Insertion Policy                               11.8% (2)        29, 89
Mandated Use of a CVC Insertion Checklist                         11.8% (2)        84, 87


                    Infect Control Hosp Epidemiol 2008;29:440-2
National Reduction in CLA-BSI




                JAMA 2009;301:727-36
MRSA Central Line-Associate BSI




 50% reduction in MRSA CLA-BSI (0.43 vs 0.21 per 1000 catheter-days)

                                       JAMA 2009;301:727-36
                               Hospital-Acquired UTI
                                     • 40% of healthcare-associated infections
                                     • 80% due to indwelling urethral catheter

                            Survey of Hospital Monitoring
                                                                        Potential Strategies
                    100
No monitoring (%)




                     90                                                 • Insertion/care
                     80
                                                                        • Catheter reminders/
                     70
                     60                                                     automatic stop orders
                     50                                                 • Bladder US scanners
                     40                                                 • Condom catheters
                     30                                                 • Antimicrobial catheters
                     20
                     10
                                                                       Clin Infect Dis 2008;46:243-50
                      0
                          Presence   Duration   UTI rates   Feedback

                                           Aymptomatic bacteriuria
                                                      vs.
                          Symptomatic UTI in patients without localizing GU symptoms
                       CA-UTI Pathogens
                               NHSN 2006-2007
               Coag neg                  S, aureus, 2%
          Staphylococcus, 3%                              Acinetobacter , 1%
                                                                                    E. coli, 21%
Enterobacter sp, 4%


Klebsiella sp, 9%




   Pseudomonas ,
       10%                                                                     Candida sp, 21%
                               Enterococcus, 15%

                                           Infect Control Hosp Epidemiol 2008;29:996-1011
        Catheter-Associated UTI
• Duration of catheterization is primary risk
• Providers unaware of catheter status
  – Students              21%
  – Interns               22%
  – Residents             27%
  – Attendings            38%
• Daily assessment of need, especially
  when transferred from ICU to floor
   Am J Med 2000;109:476-80
    Ventilator-Associated Pneumonia
• Rate 0.7 – 7.4 per 1000 ventilator days (NHSN 2009)
    – 10-30% of intubated patients
    – Incidence increases with duration of MV
        • Day 1-5: 3% risk per day
        • Day 6-10: 2% risk per day
        • > 10 days: 1% risk per day
•   Attributable mortality rate 33-50%
•   Increased LOS 7-9 days
•   Cost of $40,000 per patient
•   Accounts for 50% of ICU antimicrobials
•   Clinical vs. microbiologic definitions
    – Poor external quality measure

Am J Respir Crit Care Med 2005;171:388-416
             NHSN Pooled Mean VAP by Unit
                                                   2009 Report
                              8
Rate per 1000 vent-days



                              7


                              6


                              5


                              4


                              3


                              2


                              1


                              0
                                    BICU   CICU   CT ICU   MICU   PICU   NICU    SICU   TICU



                          BICU:      Burn                            PICU:      Pediatric med/surg
                          CICU:      Coronary                        NICU:      Neurosurgery
                          CT ICU:    Cardiothoracic                  SICU:      Surgical
                          MICU:      Medical                         TICU:      Trauma

                                                              Am J Infect Control 2009;37:783-805
               “Ventilator Bundle”

• Head of bed elevation > 30 degrees
• Daily “sedation awakening” and
  assessment of readiness to extubate
• Oral care (chlorhexidine)
• Peptic ulcer disease prophylaxis
• Deep vein thrombosis prophylaxis

  *Institute for Healthcare Improvement
            Late Onset VAP Pathogens
Pathogens         July 03 – June 04   July 08 – June 09 July 09 – June 10
                       (N=138)             (N=114)            (N=83)
Acinetobacter         44 (32%)            4 (4%) ↓          4 (5%) ↓
MRSA                  32 (23%)            8 (7%) ↓          2 (2%) ↓
MSSA                  21 (15%)            30 (26%)          23 (28%)
Haemophilus           20 (14%)            24 (21%)          13 (16%)
Pseudomonas           13 (9%)             14 (12%)          15 (18%)
Enterobacter           4 (3%)             12 (11%)           4 (5%)
Klebsiella spp.        7 (5%)              7 (6%)            5 (6%)
Serratia spp.          5 (3%)              7 (6%)            1 (1%)
E. coli                6 (4%)              6 (5%)            1 (1%)
Which of the following has been demonstrated
   to reduce surgical site infections and is
 currently part of SCIP recommendations?

 A. Peri-operative prophylactic antibiotics should be given within 60 minutes
    after incision
 B. Peri-operative prophylactic antibiotics should be given within 60 minutes
    before incision and discontinued within 24 hours
 C. Peri-operative antibiotics should be continued until the drains are out
 D. Nasal carriage of S. aureus should be eradicated prior to surgery
 E. Pre-surgical bath with chlorhexidine
 Surgical Care Improvement Project
• Implemented by CDC and Centers for Medicare and
  Medicaid Services in 2002
• Nationally included procedures
   – Cardiothoracic, vascular, colon, hip or knee arthroplasty, vaginal or
     abdominal hysterectomy
• Performance measures
  (Baseline of 34,133 medicare patients in 2001)
   – Antimicrobial prophylaxis within 1 hr of incision (55.7%)
   – Antimicrobial agent c/w current guidelines (92.6%)
   – Discontinuation within 24 hours after surgery (40.7%)
• Also, clipping rather than shaving, normothermia, glucose
  control, morning beta-blocker, DVT prophylaxis
• Role of MRSA screening?
                                             Arch Surg 2005;140:174-82
Perioperative Prophylactic Antibiotics
                            Timing of Administration
                     14/369
                 4
                                                                                15/441
Infections (%)




                 3
                                                                  1/41
                                                                         1/47
                 2
                                                           1/81
                                                   2/180
                 1
                            5/699
                                    5/1009

                 0
                      ≤-3     -2      -1       0     1      2      3      4        ≥5

                                           Hours From Incision
                                                                  N Engl J Med 1992;326:281-6
        Society of Thoracic Surgeons
•   Rationale
    –   Unique patient risks
        •   Cardiopulmonary bypass, systemic hypothermia
    –   Devastating sequelae of mediastinitis (7-20% mortality)
    –   No randomized studies < 48 hrs in CT surgery
•   Major Recommendations
    1. Postoperative prophylactic antibiotics are given for 48 hours or
       less
    2. Duration not dependent on chest tube removal
    3. If risk for MRSA, then vancomycin AND cefazolin
    4. Routine mupirocin administration for all patients in the absence
       of documented negative testing for staphylococcal colonization


                                   Ann Thorac Surg 2006;81:397-404
                                   Ann Thorac Surg 2006;83:1569-76
   Is Vancomycin Alone Adequate?
                                    Pathogens causing deep SSI following
                                      CABG, Hip and Knee Arthroplasty


                                                                                  Coagulase-negative
                        S. aureus, 40%                                            Staphylococci, 21%




                                                                                              Gram-negative Bacilli,
                                                                                                     20%




Acceptable for cardiac,                                                                     Other Gram-positives,
                                                                                                     4%
                                         Unknown, 7%
vascular, or orthopedic
                                                                                               Enterococcus, 3%
surgery:
                                             No Pathogen, 4%

• Beta-lactam allergy                                          Fungi, 1%
                                                                            Anaerobes, 1%


• Documented rationale
                                                                           NNIS 1994-2003
     Meta-analysis of Seven Randomized Studies:
     Glycopeptide vs. β-Lactam for Prevention of
     Surgical Site Infection after Cardiac Surgery




MSSA more frequent in vancomycin group 3.7% vs. 1.3%
(J Thorac Cardiovasc Surg 2002;123:326-32)
                                              Clin Infect Dis 2004;38:1357-63
                  Intranasal Mupirocin and
                   Surgical Site Infections
• Nasal carriage of S. aureus and risk of surgical site infection
   – Orthopedic surgery with prosthetic implants in 272 patients, RR 8.9
     (Infect Control Hosp Epidemiol 2000;21:319-323)
   – Cardiothoracic surgery in 1980 patients, OR 9.6
     (J Infect Dis 1995;171:216-9)
       • 10/10 pre- and post-surgical pairs identical by phage typing
• Randomized, double-blind, placebo-controlled trial of pre-
  surgical mupirocin in 3864 patients (N Eng J Med 2002;346:1871-7)
   – No difference in nosocomial infections, nosocomial S. aureus
     infections, or S. aureus surgical site infections
   – S. aureus carriers (N=891)
       •   4.5 fold increase in S. aureus SSI
       •   Significant reduction in S. aureus nosocomial infections (4.0 vs. 7.7)
       •   Trend towards decreased S. aureus SSI (3.7 vs. 5.9, 37%, P=0.15)
       •   Same strain in nares and site of infection in 85%
Universal Screening of Surgical Patients?
            JAMA 2008;299:1149-57
• Prospective, cross-over study of 21,754 surgical patients
   – 87% on admission
   – MRSA colonization 5.1%
• Standard practices for all patients with MRSA
   – Contact precautions
   – Adjustment of pre-op prophylaxis
   – Intranasal mupirocin and chlorhexidine body wash
• No difference in MRSA SSI (0.99 vs. 1.14 per 100)
   – 34% of MRSA carriers did not receive appropriate pre-op
     prophylaxis
   – None identified through outpatient screening developed MRSA
     infection
2% Chlorhexidine and 70% alcohol
(Chloraprep) vs. 10% Povidone
Iodine for Surgical-Site Antisepsis

 • Randomized, multi-center
 • 849 patients
 • Clean-contaminated surgery




                                      NNT: 17 patients



   N Engl J Med 2010;362:18-26
Pre-operative Chlorhexidine Baths
   Cochrane Review of six randomized trials with 10,007 patients



                                                        RR
Chlorhexidine vs. placebo                       0.91 (0.80 to 1.04)
Chlorhexidine vs. bar soap                      1.02 (0.57 to 1.84)
Chlorhexidine vs. no washing                    0.36 (0.17 to 0.79)




        Cochrane Database Syst Rev. 2007 Apr 18;(2):CD004985. Review
          It’s a small world…
26 y o medical student returns April 20, 2009 from
an international elective in Mexico. On April 27 she
presents to ED with 4 day h/o fever 39 C, cough,
HA, myalgias, and diarrhea. That same day you
hear reports of a novel Influenza A virus H1N1
associated with increased mortality in Mexico.
           Which of the following is
        MOST correct regarding influenza?
A. No special precautions are necessary for patients with suspected
   influenza since it is not very transmissible.
B. Influenza is primarily transmitted by large droplets (> 5 microns),
   therefore healthcare workers should use Droplet Precautions with a
   surgical mask with eye protection for routine care to prevent
   contamination of mouth, nose, and conjunctiva.
C. Patients with 2009 H1N1 should be placed in airborne isolation with
   use of N-95 respirators while patients with H1N1 seasonal
   influenza should be placed in droplet precautions.
D. A negative rapid antigen test rules out influenza
E. Influenza vaccination of healthcare workers does not have an
   impact on patients.
         Modes of Transmission

• Droplets
   – Thought to be primary mode of transmission
   – Coughing, sneezing, and talking
   – Heavy; settle within 6 feet of the source
• Airborne
   – Related to procedures → aerosolized particles
• Contact
   – Direct: skin-to-skin contact
   – Indirect: contact with virus in the environment
      Respiratory Protection Debate
 • CDC (during 2009-2010 influenza season)
       – Fit-tested N95 respirators for care of patients with 2009 H1N1
       – Prioritized usage if limited resources
       – Yet, Standard and Droplet Precautions for seasonal influenza?


 • Infection Control and Infectious Diseases Societies*
       – No evidence that 2009 H1N1 transmitted differently than seasonal
         influenza
       – Standard and Droplet Precautions for routine care


*Recommending organizations:
• World Health Organization (WHO)          • Infectious Disease Society of America
• Healthcare Infection Control Practices   • Society for Healthcare Epidemiology of America
  Advisory Committee (HICPAC)              • Association of Professionals in Infection Control
  Surgical Mask vs. N95 Respirator
                      Randomized Study
Characteristic              Surgical Mask   N95 Respirator    P
                               N=212            N=210
Vaccinated                   68 (30.2%)       62 (28.1%)
Lab-confirmed*               50 (23.6%)      48 (22.9%)      0.86
  RT-PCR                      6 (2.8%)        4 (1.8%)       0.75
  H1N1 serology               17 (8.0%)      25 (11.9%)      0.18
Serology without symptoms   29/44 (65.9%)   31/44 (70.5%)
Physician visits              13 (6.1%)       13 (6.2%)      0.98
Influenza-like illness,       9 (4.2%)          2 (1.0)      0.06
Fever and cough
Work-related absenteeism     42 (19.8%)        39 (18.6)     0.75

  *RT-PCR or serology                       JAMA 2009;302:1865-71
                     UW Medicine
• Standard, Droplet, and Contact Precautions for
  routine care
   – Place mask on coughing patients
   – Separate sick from non-sick patients
   – Surgical mask, eye protection, gown, and gloves

• N95 respirators for higher-risk aerosol-generating
  procedures
   –   Intubation and extubation
   –   Bronchoscopy
   –   Open suctioning of airway
   –   Cardiopulmonary resuscitation




                             Suspected or Confirmed Cases of Influenza
 43 y o woman from Eritrea with 3 week h/o
non-productive cough, fever, and night sweats
                    Now What?



AFB smear neg x 5
(3 sputum, 2 BAL)
Sputum AMTD neg
          Which of the following is the
               BEST approach?

A.   Remove from airborne isolation as a negative AMTD
     test rules out infectious TB
B.   Begin 4 drug therapy and remove patient from airborne
     isolation due to multiple negative AFB smears
C.   Begin 4 drug therapy and keep in airborne isolation
D.   Obtain interferon-gamma releasing assay (IGRA) as a
     negative result would rule out TB
 44 y o Vietnamese man with 6
 month h/o pain and swelling of
left medial thigh associated with
     fevers and night sweats
           Pulmonary Involvement in
              Extrapulmonary TB
• 72 patients with XPTB
                             25%
   36 lymph nodes
   12 pleura
                             20%
     6 CNS
     6 GI                    15%

• 57 had sputum collection   10%

• Weight loss associated     5%
  with positive sputum cx
  OR 4.3 (1.01-18.72)        0%
                                    AFB culture                   Normal CXR
                             AFB smear positive positive Abnormal CXR

                                          49% had abnormal CXR
    Chest 2008;134:589-94
                Sputum AFB Smear

• Smear positive
   – 5,000-10,000 organisms per ml
     of sputum must be present
• Smear negative, culture-
  positive TB
   – Responsible for roughly 17% of
     TB transmission in San                40-50% of pulmonary TB
     Francisco and Vancouver               cases in King County are
                                           smear negative



 Am Rev Respir Dis 1966;95:998
 Lancet 1999;353;444, Thorax 2004;59:286
Patient Safety and Infection Control
• UW Medicine Strategic Goals
  – Reduction in HAI
  – Expectation of hand hygiene with EVERY patient
    EVERY the time
• WSHA elimination of HAI by 2012
• Mandatory reporting of HAI
  – CLA-BSI, VAP, selected surgical site infections
• MRSA legislation
• Increased linkage of reimbursement to quality
  – CMS preventable “medical errors”

								
To top