Preventing Healthcare-associated Gastrointestinal Infections

Learn about the types of microorganisms that cause gastrointestinal infections in healthcare settings, understand the risk factors, and discover methods for prevention. Key points include isolation, contact precautions, decontamination, antibiotic stewardship, hand hygiene, and food production control. Definitions and non-infectious causes of diarrhea are also discussed.

• Healthcare
• Gastrointestinal
• Infections
• Prevention
• Microorganisms

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1. Prevention of Healthcare- associated Gastrointestinal Infections

2. Learning objectives December 1, 2013 1. List the types of microorganisms that can cause gastrointestinal infections (GI) associated with health care facilities. 2. Define diarrhoea. 3. Identify risk factors for GI infections. 4. Outline methods to prevent GI infections. 2

3. Time involved December 1, 2013 45 minutes 3

4. Introduction Many microbes cause GI problems Most outbreaks caused by viruses Norovirus Bacterial gastroenteritis associated with food and/or water Another cause - toxigenic strains of Clostridium difficile Food-borne infections occur Especially in low resource countries during warmer months December 1, 2013 4

5. Key points Critical elements for prevention and control: Isolation Contact Precautions Decontamination of spillages Antibiotic stewardship essential to prevent Clostridium difficile infections Hand hygiene with soap and water in outbreaks In food production - temperature control Inspection and auditing often reveal deficiencies in practices December 1, 2013 5

6. Definitions December 1, 2013 Diarrhoea 2 or more episodes of watery stools (Bristol Stool Type 7) or 3 or more episodes of loose stools (Bristol Stool Type 6) Over a period of 24 hours All cases of acute diarrhoea and/or vomiting regarded as potentially infectious 6

7. Non-infectious causes of diarrhoea Exclude when investigating infections laxative use allergic reactions chemical and physical agents nasogastric feeding inflammatory bowel disease surgery on the gastrointestinal tract constipation associated with faecal impaction December 1, 2013 7

8. Food-borne outbreak December 1, 2013 Considered when two or more persons who have consumed the same food develop gastroenteritis within 24 hours Cases occur in the same ward in short time Causes Common vehicle Poor hygiene and non-compliance of practices 8

9. Viral gastroenteritis -1 December 1, 2013 Norovirus, Adenovirus, Rotavirus Vomit major symptom Sudden and projectile Elderly most affected Often resolves spontaneously Immunosuppressed shed viruses longer 9

10. Viral gastroenteritis -2 December 1, 2013 Noroviruses highly infectious Transmission Direct Hand contact Indirect Contamination of environment, and subsequent contamination of hands 10

11. Viral gastroenteritis -3 December 1, 2013 Characteristic of outbreaks Short incubation period 15 to 48 hours Limited duration of illness 12 to 60 hours Vomiting the key symptom Affect both patients and staff 11

12. Prevention of outbreaks -1 Admissions with GI symptoms isolated or cohorted immediately Gloves and apron for all contacts patients and environment Hand washing with soap and water after every contact Alcohol-based hand rub should not be used No masks Bed linen and clothing changed daily December 1, 2013 12

13. Prevention of outbreaks -2 Environmental 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 surfaces Decontamination of all spillages of vomit and faeces Cohorting of staff and patients December 1, 2013 13

14. Decontamination of all spillages of vomit and faeces December 1, 2013 Wear personal protective equipment Disposable gloves, apron, visor or mask discard Absorb by paper towels discard Wash area Hot water and detergent then disinfect with fresh chlorine solution at 10,000 ppm Hand washing 14

15. Cohortingof staff and patients December 1, 2013 Staff from wards with cases must not work in unaffected areas until 48 hours have elapsed from the last case Affected staff should be excluded until they have been symptom-free for 48 hours 15

16. Prevention of outbreaks-3 December 1, 2013 Monitor 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 staff Visitors Restrict Gown or apron Hand hygiene while visiting and hand washing on leaving 16

17. End of outbreaks December 1, 2013 IP&C team determines when over Expert opinion: two complete incubation periods without a new case Terminal disinfection and changing of bed curtains Special attention to bathrooms and toilets 17

18. Antibiotic-associated Gastroenteritis December 1, 2013 Diarrhoea common complication in patients Disruption of the flora in intestine Can colonise with Clostridium difficile Can produce exotoxins resulting in mucosal injury and inflammation 18

19. C. difficileinfections Symptoms from mild diarrhoea to pseudomembranous colitis and perforation Risk increases with health care stay Antibiotic use major pre-disposing factor All antibiotics, especially wider spectrum, can predispose Antibiotic stewardship initiatives crucial for prevention December 1, 2013 19

20. Prevention of Antibiotic- associated Gastroenteritis -1 December 1, 2013 IP&C measures promptly enforced Hygienic interventions Hand hygiene with soap Lack of activity of alcohol on spores Gloves and disposable gowns or aprons 20

21. Prevention of Antibiotic- associated Gastroenteritis -2 Programme of Cleaning Critical to reduce environmental contamination with spores Chlorine-based compounds main product Recently, hydrogen peroxide mist has been used for terminal decontamination December 1, 2013 21

22. Prevention of Antibiotic- associated Gastroenteritis -3 December 1, 2013 Isolation of patients as soon as possible in a single room with toilet If not achievable, cohort Screening or decolonisation not recommended Single use items preferred or thorough cleaning/disinfection between patients Disposable rectal thermometers Antibiotic Stewardship 22

23. Contact Precautions December 1, 2013 23

24. Prevention of Food-borne Gastroenteritis December 1, 2013 Prevalence of healthcare-associated Salmonella and Shigella infections 3% and 2.5% respectively Hepatitis A, Campylobacter, Yersinia also cause food-related illness The role of IP&C Teams depends on facility Simple supervision to a more significant contribution IP&C personnel need to have a clear understanding of effective food hygiene 24

25. Food Hygiene Food pathogens survive and multiply within the temperature danger zone 6 C to 63 C Cold food must be served as soon as possible after removal from refrigeration Heating food to 75 C for 1-2 minutes guarantees destruction of any biological hazard Cooling of cooked food must be rapid Maintain temperature control until food is served Maintain hot holding temperatures above 63 C December 1, 2013 25

26. Common causes of food-borne infections Preparing food more than a half day in advance Storage at room temperature Inadequate cooling Inadequate reheating Undercooking Cross contamination from raw to cooked food Contamination from food handlers December 1, 2013 26

27. Food Hygiene December 1, 2013 Training should include Conditions for temperature and time Effective personal hygiene Environmental hygiene Potential sources of contamination 27

28. Hazard Analysis Critical Control Points (HACCP) December 1, 2013 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 food Identifies critical control points after which any contamination cannot be reversed Preventive measures monitored and corrected 28

29. Elements of HACCP December 1, 2013 Regular equipment cleaning and maintenance Provision of effective hygiene facilities Systems to control insects and other pests Temperature control Regular training for staff on food hygiene 29

30. Adapting HACCP to health care food production Process Concern Prevention Methods Reception Growth of pathogens. Toxin production. Contamination. Ensure 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. December 1, 2013 Temperature control. Storage Stored covered and dated Rotate stock 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. Keep food hot at >63 C. Hot holding/ Distribution Reheating Serving Avoid if possible. Reheat to >75 C. Serve as soon as possible Ensure hands and equipment clean. 30

31. Testing of food, environment, and individuals Not required to monitor food safety May be occasions when is useful Confirmation 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 practices Routine testing of food handlers not indicated (e.g. faeces) December 1, 2013 31

32. Whats on YOUR hands??! December 1, 2013 32 Bobulsky G et al, CID 2007; Farr et al, LID 2001

33. Ward kitchens precautions December 1, 2013 Kept clean Refrigerators away from direct heat or sunlight Temperature monitoring Items should be labelled, dated, and used within 72 hours Separation between raw and cooked items Place cooked above if in the same refrigerator 33

34. Kitchen auditing December 1, 2013 Checklists for every day documentation of critical points Auditing of kitchen practices Including points related to causes of foodborne illness Critical points Temperature control Compliance with hygiene practices Itemised audit sheet 34

35. Summary December 1, 2013 There are many risks of GI infections in health care Can be produced by bacteria and viruses Can be associated with incorrect IP&C practices, excessive antibiotic use and poor food/or water hygiene Most outbreaks caused by viruses and spread by contact 35

36. References 1. Lewis 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/10.3109/003655 29709011203 And Bristol Stool Scale http://en.wikipedia.org/wiki/Bristol_Stool_Scale 2. Koopmans M. Noroviruses in healthcare settings: a challenging problem. J Hosp Infect 2009; 73:331-7. December 1, 2013 36

37. References 1. Chadwick 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/h ospital_norovirus.pdf 2. World Health Organisation. Five keys to Safer Food Manual [online]. 2006. http://www.who.int/foodsafety/publications/consumer/ manual_keys.pdf 3. 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 December 1, 2013 37

38. Quiz 1. Which of the following is effective to prevent food borne infections? a) Adopting a HACCP system in food production b) Ensuring stringent temperature control when storing food c) Avoiding preparing food too far in advance d) All of the above Which of the following is NOT a strategy to prevent transmission of diarrhoea by Clostridium difficile? a) Antimicrobial prophylaxis for all surgical operations b) Using narrow spectrum antibiotics where possible c) Contact precautions for all cases of diarrhoea d) Education of staff in infection prevention and antibiotic stewardship Laboratory testing of food handlers is indicated when? a) Never b) To create awareness in workers c) To know epidemiology and causes of infections d) To identify potential risks December 1, 2013 2. 3. 38

39. International Federation of Infection Control IFIC 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, 2013 39