SlideShare a Scribd company logo
1 of 81
Download to read offline
Outbreak Investigation
of Healthcare-associated Infections
Ma. Liza Antoinette M. Gonzales, MD, MSc, FPPS,
Associate Professor, Department of Pediatrics
University of the Philippines Manila
Objectives of this session
• Define what is meant by an outbreak
• Discuss the steps of an outbreak
investigation in the hospital
• Apply the steps in a hypothetical
case of an outbreak
Healthcare-associated
Infections (HAI)
• Also referred to as “nosocomial” or “hospital-
acquired” infection, is defined as:
• An infection occurring in a patient during the
process of care in a health-care facility which
was not present or incubating at the time of
admission.
• Usually occur at 48 hours or more after
admission
• Includes infections acquired in the hospital but
appearing after discharge and occupational
infections among staff.
Garza D & Becan-McBride. Phlebotomy Handbook: Blood Collection Essentials, Seventh Edition 2005
Pearson Education.Copyright 2005
Nosocomial Infections
Risk Factors for HAI
• Prolonged use of invasive devices
• Inappropriate use of antibiotics
• High-risk and sophisticated procedures
• Immuno-suppression
• Severe underlying patient conditions
• Admission to the ICU
• Insufficient application of standard and
isolation precautions
• Inadequate infection control and
prevention measures
WHO, Infection Control. http://www.who.int/csr/bioriskreduction/infection_control/en/index.html
Risk Factors in settings with
limited resources:
• Inadequate
environmental hygienic
conditions and waste
disposal
• Poor infrastructure
• Insufficient equipment
• Understaffing
• Overcrowding
• Lack of procedure
• Poor knowledge and
application of basic
infection control
measures
• Lack of knowledge of
injection and blood
transfusion safety
• Absence of local and
national guidelines and
policies
WHO, Infection Control. http://www.who.int/csr/bioriskreduction/infection_control/en/index.html
Common Healthcare-associated
infections
• Blood-stream infection
• Central line-associated bloodstream
infections
• Hospital acquired / Ventilator-
associated pneumonia
• Catheter-associated urinary tract
infections
• Surgical site infections
What is an Outbreak?
• An Outbreak is defined as an increase in
occurrence of cases (HAI) above what is
expected in that population in that area
over a particular period of time
• Important to consider or establish
background rate
• One case of a rare occurrence or many
episodes of a common occurrence can be
an outbreak
CDC. Principles of Epidemiology in Public Health Practice . 3rd ed. Updated 2012
Epidemics and Clusters
• Epidemic - same as outbreak but used for
a wider geographic area
• Cluster - aggregation of cases in a given
area over a particular period without
regard to whether the number of cases is
more than expected; some are true
outbreaks, some are sporadic and
unrelated cases of the same or unrelated
disease
CDC. Principles of Epidemiology in Public Health Practice . 3rd ed. Updated 2012
Exercise 1
• Which of the following situations can be
an outbreak?
A. Two adult patients with COPD develop
pneumonia after admission to the general
medical wards
B. One patient in the surgical ward develops
purulent discharge on the surgical incision
site
C. 10 postpartum women develop abdominal
wound dehiscence after cesarean section
within 2 weeks
D. Two cases of varicella in the pediatric ICU
within 5 days
✔
✔
Reasons for Investigating
Outbreaks
• Identify the source and control
further transmission
• Develop strategies to prevent future
outbreaks
• Evaluate existing prevention
strategies
• Describe new diseases and learn
more about known diseases
• Address public concern
Reingold AL. Emerging Infectious Diseases 1998; 4 (1): 21-7.
Investigating an Outbreak
WHO, Infection Control. http://www.who.int/csr/bioriskreduction/infection_control/en/index.html
Systematic planning and
implementation of an outbreak
investigation is necessary
Outbreak Investigations:
The 10-Step Approach
1. Identify investigation team and resources
2. Establish existence of an outbreak
3. Verify the diagnosis
4. Construct case definition
5. Find cases systematically and develop line listing
6. Perform descriptive epidemiology/develop
hypotheses
7. Evaluate hypotheses/perform additional studies as
necessary
8. Implement control measures
9. Communicate findings
10. Maintain surveillance
1. Identify the Investigation team
and resources
• Once an outbreak is suspected, notify
appropriate individuals and departments in the
institution (Chief of the affected service, head
nurse of the unit, hospital administration)
• Establish an Outbreak Investigation Team with
clear delineation of responsibilities
• Cooperation of various healthcare professionals
is essential for efficient investigation and
implementation of control measures
• Identify available resources: personnel,
supplies, laboratory
Who should be part of the
Outbreak Investigation Team?
• Infection control staff must be part
of the outbreak team.
• Other members:
– Local – Hospital Epi teams,
microbiologist, other trained medical or
clinical personnel
– National - Disease Investigation
Specialists; DOH-Epidemiology Bureau
– Others – WHO, Philippine FDA
2. Confirmation of Outbreak
• Confirm whether there is an
outbreak by reviewing the following:
– preliminary information on the number
of potential cases
– available microbiology
– severity of the problem
– demographic data of cases
– place and time
• Review definition of OUTBREAK
3. Verify the Diagnosis
• Review existing data
– Medical records/charts
– Surveillance records
– Microbiology
– Other Laboratory reports and records
• Interview unit medical/clinical personnel
and paramedical staff
• Clinical observations
• Contact Hospital Epidemiologist &
Infection Control team
• Conduct clinical testing if needed
4. Construct Case Definition
• Case definition is a set of standard criteria for
classifying whether a person has a particular
disease, syndrome, or other health condition.
• Decide what constitutes a case, what you are
looking for
• Narrow enough to focus efforts but broad
enough to catch all the cases
• Define 3 essential characteristics of disease:
Person, Place, Time
• A gradient of definition based on level of
evidence (as suspected, probable, or
definite/confirmed case) is often helpful
Case Definition
• Use previously published, validated
definitions if available and applicable
– e.g. CDC/NHSN Surveillance Definitions for
Specific Types of Infections 2017
• Where not available, use standardized
written case definitions to ensure precise
surveillance.
• Use the same definitions for accurate and
valid comparisons of data over time and
across institutions
CDC/NHSN 2017 Surveillance Definitions
for Specific Types of Infections
• Primary bloodstream infections (BSI): Laboratory-
confirmed bloodstream infections (LCBI) that are not
secondary to an infection at another body site
• Central line-associated BSI (CLABSI): A
laboratory-confirmed bloodstream infection (LCBI)
where central line (CL) or umbilical catheter (UC)
was in place for >2 calendar days on the date of
event, with day of device placement being Day 1,
AND the line was also in place on the date of event
or the day before.
CDC/NHSN 2017 Surveillance Definitions for
Specific Types of Infections
• Pneumonia (PNEU) - identified by using a
combination of imaging (new or progressing
abnormalities on chest imaging test), clinical(e.g.
New onset or worsening purulent sputum or cough,
or dyspnea or tachypnea and laboratory criteria
(culture of blood/respiratory specimens or
histopathologic test).
• Ventilator-associated pneumonia (VAP): A
pneumonia where the patient is on mechanical
ventilation for >2 calendar days on the date of event,
with day of ventilator placement being Day 1, AND
the ventilator was in place on the date of event or
the day before.
CDC/NHSN 2017 Surveillance Definitions for
Specific Types of Infections
• Non-Catheter-associated Urinary Tract Infection
(Non-CAUTI) - Patient has at least one of the ff:
fever, suprapubic tenderness, costovertebral angle
pain or tenderness, urinary frequency, urinary
urgency, dysuria AND has a urine culture with no
more than two species of organisms identified, one
of which is a bacterium of ≥105 CFU/ml.
• Catheter-associated UTI (CAUTI): A UTI where an
indwelling urinary catheter was in place for >2 days
or the day before AND patient has clinical signs and
symptoms of UTI AND has a urine culture with no
more than two species of organisms identified, one
of which is a bacterium of ≥105 CFU/ml.
Sample Case Definition: Outbreak of
Hospital-acquired Pneumonia
Person
Place
Time
Components of
Case Definition
Hospital-acquired Pneumonia
• Occurring after admission to
ward A
• During May-August 2016
• New/progressing abnormalities on
chest imaging test AND new onset or
worsening purulent sputum/cough, or
dyspnea or tachypnea AND positive
culture of blood or resp. specimens
5. Find cases systematically
and develop line listing
• How do you find cases?
– Microbiology data
– Infection control or surveillance records
– Discussions with clinicians
– Pharmacy records
– Medical records
– Nursing charts
– Pathology reports
Develop Line Lists
• Line list - used to summarize information
• What to put on a Line List
– Demographic information (age, sex,
occupation, hospital numbr, date of
admission, date of surgery, etc)
– Clinical Data: Signs and Symptoms, Onset
dates and/or times, Outcomes, Lab results,
Antimicrobials, other Medications
– Exposure information : procedures or
surgery; medical devices or equipment
– Other potentially relevant data
Sample Line List from an Investigation
of Acute gastroenteritis
• Don’t get bogged down with case
definitions and capturing all cases
• Goal of Outbreak investigation is
NOT to find and describe every case
• Goal is to STOP THE OUTBREAK –
do not need to find every case
6. Perform Descriptive epidemiology
and develop hypotheses
• Examine the distribution of a disease in a
specific or defined population (“at-risk
population”)
• Describe the basic features of its
distribution in terms of Person, Place,
Time
• Assess Time-trend: Point source,
propagated or circulating, recurrent or
cyclical, seasonal, combination
• Conduct surveillance
Surveillance
• Defined as: “The ongoing, systematic
collection, analysis, interpretation, and
dissemination of data regarding a health-
related event for use in public health
action to reduce morbidity and mortality
and to improve health.’’
• Basic components of a surveillance
system:
– Data collection
– Procedure for evaluating data and making
comparisons
– A means for disseminating the results
Centers for Disease Control and Prevention. Updated guidelines for evaluating public health surveillance systems:
recommendations from the guidelines working group. MMWR 2001;50:1-35.
Retrospective Surveillance
• Retrospective surveillance
– Comprehensive review of sequential
events in the medical records and
examination of information even after
patient is discharged
– Avoids time-consuming efforts of
locating and reviewing charts
– Disadvantage: does not permit
interactions with ongoing caregivers or
verifying data collected
Active Surveillance
• Prevalence study (Cross-sectional study)
– Identify all patients with HAI hospitalized at a
given point time in the entire hospital, or on
selected units.
– Useful for conducting initial assessment of
current issues, before proceeding to a more
focused continuing active surveillance
programme.
– Outcome measure is a Prevalence Rate.
Active Surveillance
• Incidence study (Prospective, longitudinal)
– Detect new cases during the surveillance period
– Preferable if data can be collected regularly and patient
is still under the care of the institution
– Able to capture information in real time, interview
patient’s caregivers, interactively obtain or observe
findings that may not be recorded in the patient record
– More effective in detecting differences in infection
rates, to follow trends, to link infections to risk factors,
and for inter-hospital and inter-unit comparisons
– Outcome measure are Incidence rates, Attack rates,
and Infection ratio
Prevalence Study (Cross-sectional study)
Patient A
Patient B
Patient C
Patient D
Patient E
Patient F
Patient G
Patient H
Point Prevalence- assess
only HAIs active on the day
of the survey
7 days
Period Prevalence- include HAIs active on
the day of the survey and those active during
a predefined period before the survey day
Exercise: Compute HAI Prevalence rate
Patient A
Patient B
Patient C
Patient D
Patient E
Patient F
Patient G
Patient H
7 days
Point Prevalence
2/8
(25%
)
Period Prevalence 5/8
(62.5%)
Incidence Study (Prospective)
Patient A
Patient B
Patient C
Patient D
Patient E
Patient F
Patient G
Patient H
Incidence of HAI
2/8
(25%)
4 weeks
Epidemic Curves
• Graph used to depict the time
course of an outbreak or epidemic
• Provides a simple visual display of
the outbreak's magnitude and time
trend
• Graphs the number of cases by date
or time of onset of illness.
• Suggests type of exposure or time
of exposure
Time of Exposure is Possible if
Agent is known
Zack Moore, MD, MPH, Medical Epidemiologist. North Carolina Division of Public Health
Zack Moore, MD, MPH, Medical Epidemiologist. North Carolina Division of Public Health
Possible Agent can be Identified if
Exposure Time is known
Epidemic Curves
Outbreak Investigation of Healthcare Associated Infections
Environmental Sampling
• Vital part of investigation
• Should be done with (not instead of)
epidemiologic investigation
• Ideally, epidemiologic results guide sample
collection – should not be taken randomly
• Can support epidemiologic findings
• Positive or negative results can be misleading or
difficult to interpret (consider contamination)
• Understand limitations
Environmental and personnel culturing should NOT be
the first step in any outbreak investigation!
Calculation of HAI Rates
• The frequency of infection can be estimated by
prevalence and incidence rates
• Rates are obtained by dividing a numerator by a
denominator
• Numerator - event of interest which can be:
– number of infections
– number of infected patients observed
• Denominator - can be any of the following:
– Total population in which the event may occur (at-risk
population)
– Number of patient-days of risk
Ducel G et al. Prevention of hospital-acquired infections. A practical guide. WHO Geneva 2002.
Ways to Calculate HAI Rate
• Prevalence rate (%)
– Number of patients with HAI (total or specific
infection) at the time of study divided by
Total number of patients observed or exposed
at the same time X100
• Cumulative Incidence rate (Attack rate)
– Number of new infections acquired in a period
divided by Total number of patients observed
or exposed at the same time X100
Lee TB et al. . Recommended practices for surveillance: APIC,Inc.Am J Infect Control
2007;35:427-40; Ducel G et al. Prevention of hospital-acquired infections. A practical guide.
WHO Geneva 2002 .
Ways to Calculate HAI Rate
• Risk Adjusted Infection Rates – rates are
expressed in terms of specific exposures
rather than using an overall census
denominator.
– Incidence rate PER PATIENT-DAYS: number
of new HAI pooled throughout the month(s)
divided by the patient-days of stay x 1000
– Incidence rate PER DEVISE DAYS: number of
new HAI pooled throughout the month(s)
divided by the device-days x 1000 (e.g.
catheter days)
Lee TB et al. . Recommended practices for surveillance: APIC,Inc.Am J Infect Control
2007;35:427-40; Ducel G et al. Prevention of hospital-acquired infections. A practical guide.
WHO Geneva 2002 .
Exercises
Calculate the Surveillance rate for the following:
6.2
1. Nosocomial sepsis rate (Prevalence rate)
No. of At-risk patients in one
month (newly admitted
patients + patients carried
over from previous month)
No. of sepsis
cases
Prevalence Rate (%)
(no. of sepsis cases ÷ no.
at-risk patients)
242 15
1.6
2. Procedure-specific SSI rate (Incidence rate)
No. of cesarean section
operations in one month
Total No. of New
Skin/Soft tissue
infection
Incidence Rate (%)
(no. of new SSI ÷ no. of
cesarean sec performed)
122 2
Exercises
4. Ventilator-associated pneumonia rate (Incidence rate per
device days)
No. of ventilator
days in pediatric
ICU
No. of ventilator-
associated
pneumonias in
pediatric ICU
Rate per 1000
ventilator days (no. of
ventilator-associated
pneumonias ÷ no. of
ventilator days x 1000)
801 5
Calculate the Surveillance rate for the following:
6.2
3. Urinary tract Infection (Incidence rate per patient-days)
Total patients-days of stay
during specified time
period)
No. of
UTI cases
Rate per 1000 patient-
days (number of UTI ÷
total patient-days x
1000)
989 11 11.1
Hypothesis Formulation
• Formulate hypothesis to explain the
observed increase in incidence
• Look into associations
• Formulate a hypothesis on the type
of infection (exogenous,
endogenous)
• Tentatively identify the source and
route of infection
7. Evaluate hypotheses and perform
additional studies as necessary
• Test hypothesis about the relationship of a
disease to a specific cause
• Determine Cause-effect relationship by
conducting an epidemiologic study that relates
the exposure of interest to the outcome of
interest
• Typical study designs: cohort, case-control,
experimental design
• Determine the appropriate approach to
surveillance depending on the issue being
surveyed and available resources
Analytical Epidemiologic
Studies
• Cohort Studies (prospective or
retrospective)
– Include everyone who could have been
exposed
– A cohort study is feasible only when the
population is well defined and can be followed
over a period of time.
• Case-Control Studies (retrospective)
– Compare exposures among ill persons (case-
patients) and non-ill persons (controls)
Sample Study: Cohort
Risk Ratio = Risk in exposed group/ Risk in
unexposed group
Calculation: [a/a+b) ÷ c/c+d]
Ex. (25/53) ÷ (2/28) = 0.47/0.07 = 6.7
Interpretation: Exposed persons were 6.7x more
likely to develop HAI than those unexposed
HAI Cases No HAI
(Control)
total
Exposure 25 (a) 28 (b) 53
No exposure 2 (c) 26 (d) 28
Total 27 54 81
Sample Study: Case-Control
Odds Ratio: (No. exposed cases x No.unexposed
controls) divided by (No. exposed controls x
No.unexposed cases)
Calculation: [ad/ bc]
Example: 25x26/28 x 2 = = 650/56 = 11.6
Interpretation : Persons exposed had 11.6 times the
odds of developing HAI than persons not exposed
HAI Cases No HAI
(Control)
total
Exposure 25 (a) 28 (b) 53
No exposure 2 (c) 26 (d) 28
Total 27 54 81
Analytic Studies
• Can be useful for supporting your
hypothesis if no obvious source
identified
• Not always necessary
• Time consuming and challenging
• Small number of cases limits power
8. Implement control measures
• Implement control measures to control the
outbreak
• Can occur at any point during outbreak
• Isolation, cohorting, drug or product recall
• Balance between preventing further
disease and protecting credibility and
reputation of institution
• Should be guided by epidemiologic results
in conjunction with environmental
investigation
Break the Chain of Infection
… stop the spread of Infectious
diseases
Hepatitis C Outbreak in Nevada
Endoscopy Center, 2008
• Potentially exposed > 50,000 patients to Hepatitis C and
other infectious diseases; 8 acute hepatitis C cases linked
directly, 10 hepatitis C cases possibly linked
• Identified breaches contributed to transmission:
– Reuse of syringes for more than one patient
– Reuse of single use vials of propofol for multiple patients
– Poor hand hygiene practices
MMWR May 16, 2008 / 57(19);513-7
General Infection Control Practices
that Prevent Nosocomial Infections
• Hand hygiene
• Standard (universal) precautions
• Isolation precautions : contact, droplet, and
airborne spread
• Environmental cleaning and disinfection
• Disinfection and sterilization of medical devices
and patient care equipment
• Enhanced healthcare provider education and
training
• Cohorting patients or staff
• Maintain adequate staffing levels
Siegel JD, et al. HICPAC 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents
in Healthcare Settings, June 2007 ; Pittet D, et al Lancet Infect Dis 2006; 6:641.; Haley RW et al. Am J Epidemiol
1985; 121:182.; Whitehouse JD et al.. Compr Ther 1998; 24:71.
Sample Control measures
for Outbreak Management
Ducel G et al. Prevention of hospital-acquired infections. A practical guide. WHO Geneva 2002
9. Communicate findings
• During the investigation of an outbreak, timely,
up-to-date information must be communicated to
the hospital administration, department or unit,
and in some cases, to the public.
• Develop a means for disseminating the results to
those who have a need to know (those involved
in improving those outcomes).
• Include measures to prevent such outbreaks in
the future.
• Media attention desirable if public action needed
Write the Final Report
• A final report on the outbreak
investigation should be prepared
• It should describe the outbreak,
interventions, and effectiveness, and
summarize the contribution of each team
member participating in the investigation.
• It should also make recommendations to
prevent future occurrence.
• This report can be in the medical
literature, and may be considered as a
legal document.
10. Maintain surveillance
• Follow-up investigation to determine if
there are additional case-patients
• Decide if outbreak is over
• Document effectiveness of control
measures
• Determine if the outbreak has spread
outside its original area or the area where
the interventions were targeted.
Exercise:
Outbreak
Investigation of
HAI
Example of a Hospital
Outbreak Investigation
• March 25, 2017, a report was received that there
were 12 cases of neonatal sepsis in the Neonatal
intensive Care Unit (NICU).
• The first case was reported on March 4:
Klebsiella pneumoniae was isolated from a
preterm baby with severe respiratory distress.
• Within a period of three weeks from the day the
first case was reported, 11 neonates developed
culture proven K. pneumoniae septicemia.
• Nine of the 12 (7 male, 5 female) septicemic
neonates were preterm (75% preterm), 3 were
fullterm.
Example #1
• First clinical manifestation occurred at a mean of
4.8 + 0.43 days after admission (range 3-10days).
• Main presenting complaint: respiratory distress
associated with lethargy and feeding difficulties.
• Disseminated intravascular coagulation (DIC)
seen in 6 neonates
• Necrotizing enterocolitis (NEC) seen in 3
neonates
• Deaths: 10 deaths due to septic shock (83%).
Outbreak Investigations:
The 10-Step Approach
1. Identify investigation team and resources
2. Establish existence of an outbreak
3. Verify the diagnosis
4. Construct case definition
5. Find cases systematically and develop line listing
6. Perform descriptive epidemiology/develop
hypotheses
7. Evaluate hypotheses/perform additional studies as
necessary
8. Implement control measures
9. Communicate findings
10. Maintain surveillance
Is there an Outbreak?
Month
Total No. of
NICU patients
No. of
HCAI
HCAI
nosocomial)
infection)
Rate
January
2017 148 6 4.05%
February
2017 145 4 2.75%
March
2017 150 12 8.0%
Outbreak Investigations:
The 10-Step Approach
1. Identify investigation team and resources
2. Establish existence of an outbreak
3. Verify the diagnosis
4. Construct case definition
Verify the diagnosis
• Review existing data
– Medical records/charts
– Surveillance records
– Microbiology
– Other Laboratory reports and records
• Interview unit medical/clinical
personnel and paramedical staff
• Clinical observations
Case Definition: Outbreak of
Sepsis (Bloodstream Infection)
Person
Place
• Patient ≤ 1 year of age has at least
one of the ff SSx : fever (>38.0oC),
hypothermia (<36.0oC), apnea, or
bradycardia AND K. pneumoniae
identified from blood is not related to
an infection at another site
Time
Components of
Case Definition
Lab-Confirmed Bloodstream
Infection Criteria (LCBI)
• Occurring after admission to
the NICU
• During March 1-31, 2017
Outbreak Investigations:
The 10-Step Approach
1. Identify investigation team and resources
2. Establish existence of an outbreak
3. Verify the diagnosis
4. Construct case definition
5. Find cases systematically and develop line listing
Example #1: List of Patients with Klebsiella
pneumoniae Nosocomial Sepsis
Px AOG DOB Date of
onset
Umbilic
cannula
Mech.
Vent
NGT NEC DIC Died
1 Preterm 2/25/17 3/4/17 Y N Y Y N N
2 Fullterm 2/27/17 3/8/17 Y N N N Y Y
3 Fullterm 2/28/17 3/8/17 Y N N N N N
4 Preterm 2/28/17 3/10/17 Y Y Y N N Y
5 Preterm 2/28/17 3/10/17 N Y N N N Y
6 Preterm 3/3/17 3/10/17 Y Y N N N Y
7 Preterm 3/5/17 3/12/17 Y Y N N N Y
8 Fullterm 3/6/17 3/12/17 N N N N Y N
9 Preterm 3/9/17 3/14/17 Y Y N N Y Y
10 Preterm 3/20/17 3/24/17 Y Y N N Y Y
11 Preterm 3/21/17 3/25/17 Y Y N Y Y Y
12 Preterm 3/22/17 3/25/17 Y Y N Y Y Y
Outbreak Investigations:
The 10-Step Approach
1. Identify investigation team and resources
2. Establish existence of an outbreak
3. Verify the diagnosis
4. Construct case definition
5. Find cases systematically and develop line listing
6. Perform descriptive epidemiology/develop
hypotheses
Example #1:
Epi Curve of NICU Outbreak
Point Source Epidemic
curve – suggests same
source over a relatively
brief period
What do we know about Klebsiella
pneumoniae sepsis?
• Klebsiella pneumoniae has been incriminated in
hospital acquired infections.
• This organism colonizes the bowel and skin and
is probably transmitted via medical staff hands.
• Nosocomial K. pneumoniae infection is
associated with a high mortality in neonates and
antimicrobial therapy in infections has been
complicated by the emergence of multi-resistant
strains.
Example #1: NICU admissions and
staffing
• Average number of monthly NICU admissions: 145 (range
135 – 155)
• At any one time, there are 12-20 neonates requiring
mechanical ventilation
• Nurse staffing has always been a problem, as shown
below:
Level of Care Nurse-to-patient Ratio
Actual Optimal*
Newborns requiring only routine care 1:12-15 1:6- 8
Newborns in transition/ req close
observation
1:6-8 1:4
Newborns requiring intermediate care 1:6-8 1: 2-3
Newborns requiring intensive care 1:4 1: 1-2
*AAP and American College of Obstetricians Gynecologists. (2012). Guidelines for Perinatal Care, 7th Edition. Elk
Grove Village, IL; National Association of Neonatal Nurses. Position Statement #3009. Minimum RN Staffing in
NICUs. Revised July 2008.
Example #1: Environmental
Surveillance Culture Results
• Environmental surveillance cultures
identified the isolates to be the
following:
Bacterial Isolate Location
Klebsiella pneumoniae Ventilator tubings and rinsing
bottles
2 out of 6 sinks sampled in the high
risk area
Coagulase negative
Staphylococcus
2 Feeding cups out of 10 sampled
Enterobacter sp. 1 incubator out of 10 in the high risk
area
Example #1: Hypothesis on Possible
Sources of Infection
Potential exposure or
Source
Examples
Contaminated Medical
Device
ventilator tubings, suction tubings. Intravascular
lines (central or peripheral), umbilical cannula
Contaminated patient
care materials or
equipment
Drugs, IV fluids, thermometers, breastmilk
collection and storage equipment, feeding bottles
or feeding cups; malfunction of disinfection
/sterilization machines
Improper Procedures
or techniques
Improper handwashing and hand hygiene
procedures; Inadequate aseptic techniques in
intubation, suctioning, etc;
Environment inadequate or improper cleaning and
disinfection/sterilization ; contaminated or
ineffective disinfectants
Staffing High nurse-to-patient ratio; crossing of nurses
between ‘clean” and “infected” areas
Others Contaminated breastmilk
Others?
Outbreak Investigations:
The 10-Step Approach
1. Identify investigation team and resources
2. Establish existence of an outbreak
3. Verify the diagnosis
4. Construct case definition
5. Find cases systematically and develop line listing
6. Perform descriptive epidemiology/develop
hypotheses
7. Evaluate hypotheses/perform additional studies as
necessary
8. Implement control measures
Case #1: What are the Infection
Control Measures recommended to
control this outbreak?
Recomendations Yes or No
Hand hygiene
Standard (universal) precaution
Isolation precautions : contact, droplet, and airborne
spread
Environmental cleaning and disinfection
Disinfection and sterilization of medical devices and
patient care equipment
Enhanced healthcare provider education and training
Cohorting patients
Maintain adequate staffing levels
Others:
e.g. Closing of unit
Ye
s
Ye
s
Ye
s
Ye
s
Ye
s
Ye
s
Ye
s
Ye
s
Ye
s
Outbreak Investigations:
The 10-Step Approach
1. Identify investigation team and resources
2. Establish existence of an outbreak
3. Verify the diagnosis
4. Construct case definition
5. Find cases systematically and develop line listing
6. Perform descriptive epidemiology/develop
hypotheses
7. Evaluate hypotheses/perform additional studies as
necessary
8. Implement control measures
9. Communicate findings
10. Maintain surveillance
Important Points
• Epidemiologic investigations are
essential to determine source of
outbreaks
• Be systematic, consider each step
• Follow the steps if appropriate
• Multiple steps may happen at once
• Might need to repeat steps
Outbreak Investigation of Healthcare Associated Infections

More Related Content

What's hot

Hospital Acquired Infection-Management, Prevention-Control & Awareness
Hospital Acquired Infection-Management, Prevention-Control & AwarenessHospital Acquired Infection-Management, Prevention-Control & Awareness
Hospital Acquired Infection-Management, Prevention-Control & AwarenessDr. Priyanka Wandhe
 
Principles and practices in hospital infection control
Principles and practices in hospital infection controlPrinciples and practices in hospital infection control
Principles and practices in hospital infection controlCentral Govt, India
 
Outbreak – investigation & management
Outbreak – investigation & managementOutbreak – investigation & management
Outbreak – investigation & managementJeba Jane
 
Infection control and safety measurs
Infection control and safety measursInfection control and safety measurs
Infection control and safety measursdeepak patel
 
Diagnostic stewardship in respiratory viral infections multipronged approa...
Diagnostic stewardship  in respiratory viral infections   multipronged approa...Diagnostic stewardship  in respiratory viral infections   multipronged approa...
Diagnostic stewardship in respiratory viral infections multipronged approa...SOMESHWARAN R
 
EPIDEMIOLOGY OF TUBERCULOSIS
EPIDEMIOLOGY OF TUBERCULOSISEPIDEMIOLOGY OF TUBERCULOSIS
EPIDEMIOLOGY OF TUBERCULOSISSantosh Yadav
 
Infection control practices
Infection control practicesInfection control practices
Infection control practicesJohny Wilbert
 
Outbreak investigation
Outbreak investigationOutbreak investigation
Outbreak investigationismailzai
 
Nosocomial infection
Nosocomial infectionNosocomial infection
Nosocomial infectionNursing Path
 
Vaccination of healthcare workers, Dr. V. Anil Kumar
Vaccination of healthcare workers, Dr. V. Anil KumarVaccination of healthcare workers, Dr. V. Anil Kumar
Vaccination of healthcare workers, Dr. V. Anil Kumarohscmcvellore
 
Out break investigation
Out break investigationOut break investigation
Out break investigationutpal sharma
 
Outbreak – management
Outbreak – managementOutbreak – management
Outbreak – managementJanedoctor
 
Health care associated infections
Health care associated infectionsHealth care associated infections
Health care associated infectionsDr.Hemant Kumar
 
Safe injection practices
Safe injection practicesSafe injection practices
Safe injection practicesMeenakshic23
 
Monitoring mdro in healthcare
Monitoring mdro in healthcareMonitoring mdro in healthcare
Monitoring mdro in healthcarePathKind Labs
 
Emerging &amp; re emerging infections
Emerging &amp; re emerging infectionsEmerging &amp; re emerging infections
Emerging &amp; re emerging infectionsswati shikha
 
Practical methods to control hospital acquired infections
Practical methods to control hospital acquired infectionsPractical methods to control hospital acquired infections
Practical methods to control hospital acquired infectionsfaiqa_ali
 

What's hot (20)

Hospital Acquired Infection-Management, Prevention-Control & Awareness
Hospital Acquired Infection-Management, Prevention-Control & AwarenessHospital Acquired Infection-Management, Prevention-Control & Awareness
Hospital Acquired Infection-Management, Prevention-Control & Awareness
 
Principles and practices in hospital infection control
Principles and practices in hospital infection controlPrinciples and practices in hospital infection control
Principles and practices in hospital infection control
 
Outbreak – investigation & management
Outbreak – investigation & managementOutbreak – investigation & management
Outbreak – investigation & management
 
Infection control and safety measurs
Infection control and safety measursInfection control and safety measurs
Infection control and safety measurs
 
Hospital Acquired Infections Role for Everyone by Dr.T.V.Rao MD
Hospital Acquired InfectionsRole for Everyone by Dr.T.V.Rao MDHospital Acquired InfectionsRole for Everyone by Dr.T.V.Rao MD
Hospital Acquired Infections Role for Everyone by Dr.T.V.Rao MD
 
Infection prevention and control of epidemic and pandemic
Infection prevention and control of epidemic  and pandemicInfection prevention and control of epidemic  and pandemic
Infection prevention and control of epidemic and pandemic
 
Diagnostic stewardship in respiratory viral infections multipronged approa...
Diagnostic stewardship  in respiratory viral infections   multipronged approa...Diagnostic stewardship  in respiratory viral infections   multipronged approa...
Diagnostic stewardship in respiratory viral infections multipronged approa...
 
EPIDEMIOLOGY OF TUBERCULOSIS
EPIDEMIOLOGY OF TUBERCULOSISEPIDEMIOLOGY OF TUBERCULOSIS
EPIDEMIOLOGY OF TUBERCULOSIS
 
Infection control practices
Infection control practicesInfection control practices
Infection control practices
 
Outbreak investigation
Outbreak investigationOutbreak investigation
Outbreak investigation
 
Nosocomial infection
Nosocomial infectionNosocomial infection
Nosocomial infection
 
Vaccination of healthcare workers, Dr. V. Anil Kumar
Vaccination of healthcare workers, Dr. V. Anil KumarVaccination of healthcare workers, Dr. V. Anil Kumar
Vaccination of healthcare workers, Dr. V. Anil Kumar
 
Out break investigation
Out break investigationOut break investigation
Out break investigation
 
Outbreak – management
Outbreak – managementOutbreak – management
Outbreak – management
 
Health care associated infections
Health care associated infectionsHealth care associated infections
Health care associated infections
 
Safe injection practices
Safe injection practicesSafe injection practices
Safe injection practices
 
Monitoring mdro in healthcare
Monitoring mdro in healthcareMonitoring mdro in healthcare
Monitoring mdro in healthcare
 
Emerging &amp; re emerging infections
Emerging &amp; re emerging infectionsEmerging &amp; re emerging infections
Emerging &amp; re emerging infections
 
Practical methods to control hospital acquired infections
Practical methods to control hospital acquired infectionsPractical methods to control hospital acquired infections
Practical methods to control hospital acquired infections
 
Introduction to epidemiology
Introduction to epidemiologyIntroduction to epidemiology
Introduction to epidemiology
 

Viewers also liked

Principles of outbreak investigation
Principles of outbreak investigationPrinciples of outbreak investigation
Principles of outbreak investigationVivek Varat
 
Hospital Infection Control
Hospital Infection ControlHospital Infection Control
Hospital Infection ControlNc Das
 
Infection control powerpoint 1
Infection control powerpoint 1Infection control powerpoint 1
Infection control powerpoint 1gregoryjnewman
 

Viewers also liked (15)

Principles of outbreak investigation
Principles of outbreak investigationPrinciples of outbreak investigation
Principles of outbreak investigation
 
Epidemiology and Hand Hygiene
Epidemiology and Hand HygieneEpidemiology and Hand Hygiene
Epidemiology and Hand Hygiene
 
Outbreak Investigation
Outbreak InvestigationOutbreak Investigation
Outbreak Investigation
 
WHO Guidelines on Core Components of Infection Prevention and Control (IPC) P...
WHO Guidelines on Core Components of Infection Prevention and Control (IPC) P...WHO Guidelines on Core Components of Infection Prevention and Control (IPC) P...
WHO Guidelines on Core Components of Infection Prevention and Control (IPC) P...
 
Evidence-based Practice in Infection Control and Prevention
Evidence-based Practice in Infection Control and PreventionEvidence-based Practice in Infection Control and Prevention
Evidence-based Practice in Infection Control and Prevention
 
Healthcare Waste Management
Healthcare Waste ManagementHealthcare Waste Management
Healthcare Waste Management
 
The Challenging Role of an Infection Control Nurse
The Challenging Role of an Infection Control NurseThe Challenging Role of an Infection Control Nurse
The Challenging Role of an Infection Control Nurse
 
National Standards in Infection Control for Healthcare Facilities
National Standards in Infection Control for Healthcare FacilitiesNational Standards in Infection Control for Healthcare Facilities
National Standards in Infection Control for Healthcare Facilities
 
APSIC and WHO Sterilization and Instrument Reprocessing Guidelines
APSIC and WHO Sterilization and Instrument Reprocessing GuidelinesAPSIC and WHO Sterilization and Instrument Reprocessing Guidelines
APSIC and WHO Sterilization and Instrument Reprocessing Guidelines
 
Care of the Environment
Care of the EnvironmentCare of the Environment
Care of the Environment
 
Directions of IPC in the Philippines
Directions of IPC in the PhilippinesDirections of IPC in the Philippines
Directions of IPC in the Philippines
 
Management Strategies and Outcomes of MDRO Infections
Management Strategies and Outcomes of MDRO InfectionsManagement Strategies and Outcomes of MDRO Infections
Management Strategies and Outcomes of MDRO Infections
 
Isolation Precaution
Isolation PrecautionIsolation Precaution
Isolation Precaution
 
Hospital Infection Control
Hospital Infection ControlHospital Infection Control
Hospital Infection Control
 
Infection control powerpoint 1
Infection control powerpoint 1Infection control powerpoint 1
Infection control powerpoint 1
 

Similar to Outbreak Investigation of Healthcare Associated Infections

hospital outbreak management.pptx
hospital outbreak management.pptxhospital outbreak management.pptx
hospital outbreak management.pptxNehaPandey199
 
Outbreak investigation.
Outbreak investigation.Outbreak investigation.
Outbreak investigation.DrSunilBhoye
 
Epcm l16 outbreak investigations
Epcm l16 outbreak investigationsEpcm l16 outbreak investigations
Epcm l16 outbreak investigationsDr Ghaiath Hussein
 
Corna virus detail And corona virus in pakistan
Corna virus detail And corona virus in pakistanCorna virus detail And corona virus in pakistan
Corna virus detail And corona virus in pakistanEmaan Uppal
 
Corrections and Monkeypox Townhall.pptx
Corrections and Monkeypox Townhall.pptxCorrections and Monkeypox Townhall.pptx
Corrections and Monkeypox Townhall.pptxrahmibackup
 
Coronavirus Disease (COVID)-19 Outbeak
Coronavirus Disease (COVID)-19 OutbeakCoronavirus Disease (COVID)-19 Outbeak
Coronavirus Disease (COVID)-19 OutbeakTahseen Siddiqui
 
Outbreak investigation.pptx
Outbreak investigation.pptxOutbreak investigation.pptx
Outbreak investigation.pptxasifraza4646
 
Outbreak investigation
Outbreak investigationOutbreak investigation
Outbreak investigationAmandeep Kaur
 
Ventilator associated pneumonia (1).pptx
Ventilator associated pneumonia (1).pptxVentilator associated pneumonia (1).pptx
Ventilator associated pneumonia (1).pptxrekha reddy
 
Out break investigation of a zoonotic disease
Out break investigation of a zoonotic diseaseOut break investigation of a zoonotic disease
Out break investigation of a zoonotic diseaseMdSalauddin20
 
Covid 19 testing presentation-dr_abdelraouf
Covid 19 testing presentation-dr_abdelraoufCovid 19 testing presentation-dr_abdelraouf
Covid 19 testing presentation-dr_abdelraoufAbdelraouf Elmanama
 
Outbreak investigation ppt
 Outbreak investigation ppt Outbreak investigation ppt
Outbreak investigation pptSHERIFFMUIDEEN1
 
Hospital acquired infections
Hospital acquired infectionsHospital acquired infections
Hospital acquired infectionsAruna Rani Behera
 
Are peripheral-i vs-an-overlooked-source-of-infection-dinner-meeting-2013-07-25
Are peripheral-i vs-an-overlooked-source-of-infection-dinner-meeting-2013-07-25Are peripheral-i vs-an-overlooked-source-of-infection-dinner-meeting-2013-07-25
Are peripheral-i vs-an-overlooked-source-of-infection-dinner-meeting-2013-07-25AYM NAZIM
 
Module 5 diagnostics
Module 5 diagnosticsModule 5 diagnostics
Module 5 diagnosticsOlgaPaterson1
 
Post exposure prophylaxis of hiv
Post exposure prophylaxis of hivPost exposure prophylaxis of hiv
Post exposure prophylaxis of hivNiranjan Chavan
 

Similar to Outbreak Investigation of Healthcare Associated Infections (20)

hospital outbreak management.pptx
hospital outbreak management.pptxhospital outbreak management.pptx
hospital outbreak management.pptx
 
outbreak
outbreakoutbreak
outbreak
 
Outbreak investigation.
Outbreak investigation.Outbreak investigation.
Outbreak investigation.
 
Corona virus 2019-nCoV
Corona virus 2019-nCoVCorona virus 2019-nCoV
Corona virus 2019-nCoV
 
Epcm l16 outbreak investigations
Epcm l16 outbreak investigationsEpcm l16 outbreak investigations
Epcm l16 outbreak investigations
 
Corna virus detail And corona virus in pakistan
Corna virus detail And corona virus in pakistanCorna virus detail And corona virus in pakistan
Corna virus detail And corona virus in pakistan
 
Corrections and Monkeypox Townhall.pptx
Corrections and Monkeypox Townhall.pptxCorrections and Monkeypox Townhall.pptx
Corrections and Monkeypox Townhall.pptx
 
Introduction to Outbreaks
Introduction to OutbreaksIntroduction to Outbreaks
Introduction to Outbreaks
 
Coronavirus Disease (COVID)-19 Outbeak
Coronavirus Disease (COVID)-19 OutbeakCoronavirus Disease (COVID)-19 Outbeak
Coronavirus Disease (COVID)-19 Outbeak
 
Outbreak investigation.pptx
Outbreak investigation.pptxOutbreak investigation.pptx
Outbreak investigation.pptx
 
Outbreak investigation
Outbreak investigationOutbreak investigation
Outbreak investigation
 
Ventilator associated pneumonia (1).pptx
Ventilator associated pneumonia (1).pptxVentilator associated pneumonia (1).pptx
Ventilator associated pneumonia (1).pptx
 
Out break investigation of a zoonotic disease
Out break investigation of a zoonotic diseaseOut break investigation of a zoonotic disease
Out break investigation of a zoonotic disease
 
Covid 19 testing presentation-dr_abdelraouf
Covid 19 testing presentation-dr_abdelraoufCovid 19 testing presentation-dr_abdelraouf
Covid 19 testing presentation-dr_abdelraouf
 
Outbreak investigation ppt
 Outbreak investigation ppt Outbreak investigation ppt
Outbreak investigation ppt
 
Hospital acquired infections
Hospital acquired infectionsHospital acquired infections
Hospital acquired infections
 
Are peripheral-i vs-an-overlooked-source-of-infection-dinner-meeting-2013-07-25
Are peripheral-i vs-an-overlooked-source-of-infection-dinner-meeting-2013-07-25Are peripheral-i vs-an-overlooked-source-of-infection-dinner-meeting-2013-07-25
Are peripheral-i vs-an-overlooked-source-of-infection-dinner-meeting-2013-07-25
 
Module 5 diagnostics
Module 5 diagnosticsModule 5 diagnostics
Module 5 diagnostics
 
Post exposure prophylaxis of hiv
Post exposure prophylaxis of hivPost exposure prophylaxis of hiv
Post exposure prophylaxis of hiv
 
survillance.pptx
survillance.pptxsurvillance.pptx
survillance.pptx
 

More from Philippine Hospital Infection Contol Nurses Associaton (PHICNA) Inc.

More from Philippine Hospital Infection Contol Nurses Associaton (PHICNA) Inc. (20)

Epidemics and Epidemic Investigation
Epidemics and Epidemic InvestigationEpidemics and Epidemic Investigation
Epidemics and Epidemic Investigation
 
2016 WHO Guidelines on the Prevention of Surgical Site Infection (SSI)
2016 WHO Guidelines on the Prevention of Surgical Site Infection (SSI)2016 WHO Guidelines on the Prevention of Surgical Site Infection (SSI)
2016 WHO Guidelines on the Prevention of Surgical Site Infection (SSI)
 
PIDSR
PIDSRPIDSR
PIDSR
 
Local Guidelines in Infection Prevention and Control
Local Guidelines in Infection Prevention and ControlLocal Guidelines in Infection Prevention and Control
Local Guidelines in Infection Prevention and Control
 
Nurses No Harm
Nurses No HarmNurses No Harm
Nurses No Harm
 
DOH National Antibiotic Guidelines 2016 (UTI)
DOH National Antibiotic Guidelines 2016 (UTI)DOH National Antibiotic Guidelines 2016 (UTI)
DOH National Antibiotic Guidelines 2016 (UTI)
 
DOH National Antibiotic Guidelines 2016 (Surgical Prophylaxis)
DOH National Antibiotic Guidelines 2016 (Surgical Prophylaxis)DOH National Antibiotic Guidelines 2016 (Surgical Prophylaxis)
DOH National Antibiotic Guidelines 2016 (Surgical Prophylaxis)
 
DOH Antimicrobial Stewardship Program in Hospitals Manual of Procedures (MOP)...
DOH Antimicrobial Stewardship Program in Hospitals Manual of Procedures (MOP)...DOH Antimicrobial Stewardship Program in Hospitals Manual of Procedures (MOP)...
DOH Antimicrobial Stewardship Program in Hospitals Manual of Procedures (MOP)...
 
Surgical Site Infection (SSI)
Surgical Site Infection (SSI)Surgical Site Infection (SSI)
Surgical Site Infection (SSI)
 
Orientation to Surveillance
Orientation to SurveillanceOrientation to Surveillance
Orientation to Surveillance
 
Healthcare Workers’ Risks and Handling Exposures
Healthcare Workers’ Risks and Handling ExposuresHealthcare Workers’ Risks and Handling Exposures
Healthcare Workers’ Risks and Handling Exposures
 
Emerging and Re-emerging Infectious Diseases
Emerging and Re-emerging Infectious DiseasesEmerging and Re-emerging Infectious Diseases
Emerging and Re-emerging Infectious Diseases
 
Proper Donning and Doffing of PPE
Proper Donning and Doffing of PPEProper Donning and Doffing of PPE
Proper Donning and Doffing of PPE
 
Antimicrobial Stewardship
Antimicrobial StewardshipAntimicrobial Stewardship
Antimicrobial Stewardship
 
Pharmacy
PharmacyPharmacy
Pharmacy
 
Ventilator Associated Pneumonia (VAP) or Hospital Acquired Pneumonia (HAP)
Ventilator Associated Pneumonia (VAP) or Hospital Acquired Pneumonia (HAP)Ventilator Associated Pneumonia (VAP) or Hospital Acquired Pneumonia (HAP)
Ventilator Associated Pneumonia (VAP) or Hospital Acquired Pneumonia (HAP)
 
Linen and Laundry Management
Linen and Laundry ManagementLinen and Laundry Management
Linen and Laundry Management
 
Laboratory Biosafety
Laboratory BiosafetyLaboratory Biosafety
Laboratory Biosafety
 
Dietary (Food Safety)
Dietary (Food Safety)Dietary (Food Safety)
Dietary (Food Safety)
 
Infection Prevention & Control During Constructions and Renovation
Infection Prevention & Control During Constructions and RenovationInfection Prevention & Control During Constructions and Renovation
Infection Prevention & Control During Constructions and Renovation
 

Recently uploaded

person with disability and pwd act ppt.pptx
person with disability and pwd act ppt.pptxperson with disability and pwd act ppt.pptx
person with disability and pwd act ppt.pptxMUKESH PADMANABHAN
 
Artificial Intelligence in Healthcare: Challenges, Risks, Benefits
Artificial Intelligence in Healthcare: Challenges, Risks, BenefitsArtificial Intelligence in Healthcare: Challenges, Risks, Benefits
Artificial Intelligence in Healthcare: Challenges, Risks, BenefitsIris Thiele Isip-Tan
 
Introduction to Evaluation and Skin Benefits
Introduction to Evaluation and Skin BenefitsIntroduction to Evaluation and Skin Benefits
Introduction to Evaluation and Skin Benefitssahilgabhane29
 
Artificial Intelligence: Diabetes Management
Artificial Intelligence: Diabetes ManagementArtificial Intelligence: Diabetes Management
Artificial Intelligence: Diabetes ManagementIris Thiele Isip-Tan
 
EYE CANCER.pptx prepared by Neha kewat digital learning
EYE CANCER.pptx prepared by  Neha kewat digital learningEYE CANCER.pptx prepared by  Neha kewat digital learning
EYE CANCER.pptx prepared by Neha kewat digital learningNehaKewat
 
Diseases of the Respiratory System (J00-J99),.pptx
Diseases of the Respiratory System (J00-J99),.pptxDiseases of the Respiratory System (J00-J99),.pptx
Diseases of the Respiratory System (J00-J99),.pptxEMADABATHINI PRABHU TEJA
 
"ANATOMY AND PHYSIOLOGY OF THE SKIN".pdf
"ANATOMY AND PHYSIOLOGY OF THE SKIN".pdf"ANATOMY AND PHYSIOLOGY OF THE SKIN".pdf
"ANATOMY AND PHYSIOLOGY OF THE SKIN".pdfDolisha Warbi
 
Living Well Every Day: Lyons Wellness Practice | Nurtures Your Complete Health
Living Well Every Day: Lyons Wellness Practice | Nurtures Your Complete HealthLiving Well Every Day: Lyons Wellness Practice | Nurtures Your Complete Health
Living Well Every Day: Lyons Wellness Practice | Nurtures Your Complete HealthLyons Health
 
LARYNGEAL CANCER.pptx Prepared by Neha Kewat
LARYNGEAL CANCER.pptx  Prepared by Neha KewatLARYNGEAL CANCER.pptx  Prepared by Neha Kewat
LARYNGEAL CANCER.pptx Prepared by Neha KewatNehaKewat
 
NEONATAL RESPIRATORY CARE FROM A PHYSIO POV.pptx
NEONATAL RESPIRATORY CARE FROM A PHYSIO POV.pptxNEONATAL RESPIRATORY CARE FROM A PHYSIO POV.pptx
NEONATAL RESPIRATORY CARE FROM A PHYSIO POV.pptxHanineHassan2
 
Basics of Giant Cell Tumor of bone (GCTB)
Basics of Giant Cell Tumor of bone (GCTB)Basics of Giant Cell Tumor of bone (GCTB)
Basics of Giant Cell Tumor of bone (GCTB)bishwabandhuniraula
 
ARTHRITIS.pptx Prepared by monika gopal Tutor
ARTHRITIS.pptx Prepared  by monika gopal TutorARTHRITIS.pptx Prepared  by monika gopal Tutor
ARTHRITIS.pptx Prepared by monika gopal TutorNehaKewat
 
Health literacies in marginalised communities LILAC 24.pptx
Health literacies in marginalised communities LILAC 24.pptxHealth literacies in marginalised communities LILAC 24.pptx
Health literacies in marginalised communities LILAC 24.pptxPamela McKinney
 
Hematinics and Erythropoietin- Pharmacology of Hematinics
Hematinics and Erythropoietin- Pharmacology of HematinicsHematinics and Erythropoietin- Pharmacology of Hematinics
Hematinics and Erythropoietin- Pharmacology of Hematinicsnetraangadi2
 
Empathy Is a Stress Response - Choose Compassion instead
Empathy Is a Stress Response - Choose Compassion insteadEmpathy Is a Stress Response - Choose Compassion instead
Empathy Is a Stress Response - Choose Compassion insteadAlex Clapson
 
Understanding Warts and Moles: Differences, Types, and Common Locations
Understanding Warts and Moles: Differences, Types, and Common LocationsUnderstanding Warts and Moles: Differences, Types, and Common Locations
Understanding Warts and Moles: Differences, Types, and Common LocationsNeha Sharma
 
Assisted Living Care Residency - PapayaCare
Assisted Living Care Residency - PapayaCareAssisted Living Care Residency - PapayaCare
Assisted Living Care Residency - PapayaCareratilalthakkar704
 
Anatomy Shelf Notevbhhhhhhhhhhhhhhhs.pdf
Anatomy Shelf Notevbhhhhhhhhhhhhhhhs.pdfAnatomy Shelf Notevbhhhhhhhhhhhhhhhs.pdf
Anatomy Shelf Notevbhhhhhhhhhhhhhhhs.pdfhezamzaki1
 
Eating Disorders in Athletes I Sports Psychology
Eating Disorders in Athletes I Sports PsychologyEating Disorders in Athletes I Sports Psychology
Eating Disorders in Athletes I Sports Psychologyshantisphysio
 
21 NEMT Trends & Statistics to Know in 2024
21 NEMT Trends & Statistics to Know in 202421 NEMT Trends & Statistics to Know in 2024
21 NEMT Trends & Statistics to Know in 2024Traumasoft LLC
 

Recently uploaded (20)

person with disability and pwd act ppt.pptx
person with disability and pwd act ppt.pptxperson with disability and pwd act ppt.pptx
person with disability and pwd act ppt.pptx
 
Artificial Intelligence in Healthcare: Challenges, Risks, Benefits
Artificial Intelligence in Healthcare: Challenges, Risks, BenefitsArtificial Intelligence in Healthcare: Challenges, Risks, Benefits
Artificial Intelligence in Healthcare: Challenges, Risks, Benefits
 
Introduction to Evaluation and Skin Benefits
Introduction to Evaluation and Skin BenefitsIntroduction to Evaluation and Skin Benefits
Introduction to Evaluation and Skin Benefits
 
Artificial Intelligence: Diabetes Management
Artificial Intelligence: Diabetes ManagementArtificial Intelligence: Diabetes Management
Artificial Intelligence: Diabetes Management
 
EYE CANCER.pptx prepared by Neha kewat digital learning
EYE CANCER.pptx prepared by  Neha kewat digital learningEYE CANCER.pptx prepared by  Neha kewat digital learning
EYE CANCER.pptx prepared by Neha kewat digital learning
 
Diseases of the Respiratory System (J00-J99),.pptx
Diseases of the Respiratory System (J00-J99),.pptxDiseases of the Respiratory System (J00-J99),.pptx
Diseases of the Respiratory System (J00-J99),.pptx
 
"ANATOMY AND PHYSIOLOGY OF THE SKIN".pdf
"ANATOMY AND PHYSIOLOGY OF THE SKIN".pdf"ANATOMY AND PHYSIOLOGY OF THE SKIN".pdf
"ANATOMY AND PHYSIOLOGY OF THE SKIN".pdf
 
Living Well Every Day: Lyons Wellness Practice | Nurtures Your Complete Health
Living Well Every Day: Lyons Wellness Practice | Nurtures Your Complete HealthLiving Well Every Day: Lyons Wellness Practice | Nurtures Your Complete Health
Living Well Every Day: Lyons Wellness Practice | Nurtures Your Complete Health
 
LARYNGEAL CANCER.pptx Prepared by Neha Kewat
LARYNGEAL CANCER.pptx  Prepared by Neha KewatLARYNGEAL CANCER.pptx  Prepared by Neha Kewat
LARYNGEAL CANCER.pptx Prepared by Neha Kewat
 
NEONATAL RESPIRATORY CARE FROM A PHYSIO POV.pptx
NEONATAL RESPIRATORY CARE FROM A PHYSIO POV.pptxNEONATAL RESPIRATORY CARE FROM A PHYSIO POV.pptx
NEONATAL RESPIRATORY CARE FROM A PHYSIO POV.pptx
 
Basics of Giant Cell Tumor of bone (GCTB)
Basics of Giant Cell Tumor of bone (GCTB)Basics of Giant Cell Tumor of bone (GCTB)
Basics of Giant Cell Tumor of bone (GCTB)
 
ARTHRITIS.pptx Prepared by monika gopal Tutor
ARTHRITIS.pptx Prepared  by monika gopal TutorARTHRITIS.pptx Prepared  by monika gopal Tutor
ARTHRITIS.pptx Prepared by monika gopal Tutor
 
Health literacies in marginalised communities LILAC 24.pptx
Health literacies in marginalised communities LILAC 24.pptxHealth literacies in marginalised communities LILAC 24.pptx
Health literacies in marginalised communities LILAC 24.pptx
 
Hematinics and Erythropoietin- Pharmacology of Hematinics
Hematinics and Erythropoietin- Pharmacology of HematinicsHematinics and Erythropoietin- Pharmacology of Hematinics
Hematinics and Erythropoietin- Pharmacology of Hematinics
 
Empathy Is a Stress Response - Choose Compassion instead
Empathy Is a Stress Response - Choose Compassion insteadEmpathy Is a Stress Response - Choose Compassion instead
Empathy Is a Stress Response - Choose Compassion instead
 
Understanding Warts and Moles: Differences, Types, and Common Locations
Understanding Warts and Moles: Differences, Types, and Common LocationsUnderstanding Warts and Moles: Differences, Types, and Common Locations
Understanding Warts and Moles: Differences, Types, and Common Locations
 
Assisted Living Care Residency - PapayaCare
Assisted Living Care Residency - PapayaCareAssisted Living Care Residency - PapayaCare
Assisted Living Care Residency - PapayaCare
 
Anatomy Shelf Notevbhhhhhhhhhhhhhhhs.pdf
Anatomy Shelf Notevbhhhhhhhhhhhhhhhs.pdfAnatomy Shelf Notevbhhhhhhhhhhhhhhhs.pdf
Anatomy Shelf Notevbhhhhhhhhhhhhhhhs.pdf
 
Eating Disorders in Athletes I Sports Psychology
Eating Disorders in Athletes I Sports PsychologyEating Disorders in Athletes I Sports Psychology
Eating Disorders in Athletes I Sports Psychology
 
21 NEMT Trends & Statistics to Know in 2024
21 NEMT Trends & Statistics to Know in 202421 NEMT Trends & Statistics to Know in 2024
21 NEMT Trends & Statistics to Know in 2024
 

Outbreak Investigation of Healthcare Associated Infections

  • 1. Outbreak Investigation of Healthcare-associated Infections Ma. Liza Antoinette M. Gonzales, MD, MSc, FPPS, Associate Professor, Department of Pediatrics University of the Philippines Manila
  • 2. Objectives of this session • Define what is meant by an outbreak • Discuss the steps of an outbreak investigation in the hospital • Apply the steps in a hypothetical case of an outbreak
  • 3. Healthcare-associated Infections (HAI) • Also referred to as “nosocomial” or “hospital- acquired” infection, is defined as: • An infection occurring in a patient during the process of care in a health-care facility which was not present or incubating at the time of admission. • Usually occur at 48 hours or more after admission • Includes infections acquired in the hospital but appearing after discharge and occupational infections among staff.
  • 4. Garza D & Becan-McBride. Phlebotomy Handbook: Blood Collection Essentials, Seventh Edition 2005 Pearson Education.Copyright 2005 Nosocomial Infections
  • 5. Risk Factors for HAI • Prolonged use of invasive devices • Inappropriate use of antibiotics • High-risk and sophisticated procedures • Immuno-suppression • Severe underlying patient conditions • Admission to the ICU • Insufficient application of standard and isolation precautions • Inadequate infection control and prevention measures WHO, Infection Control. http://www.who.int/csr/bioriskreduction/infection_control/en/index.html
  • 6. Risk Factors in settings with limited resources: • Inadequate environmental hygienic conditions and waste disposal • Poor infrastructure • Insufficient equipment • Understaffing • Overcrowding • Lack of procedure • Poor knowledge and application of basic infection control measures • Lack of knowledge of injection and blood transfusion safety • Absence of local and national guidelines and policies WHO, Infection Control. http://www.who.int/csr/bioriskreduction/infection_control/en/index.html
  • 7. Common Healthcare-associated infections • Blood-stream infection • Central line-associated bloodstream infections • Hospital acquired / Ventilator- associated pneumonia • Catheter-associated urinary tract infections • Surgical site infections
  • 8. What is an Outbreak? • An Outbreak is defined as an increase in occurrence of cases (HAI) above what is expected in that population in that area over a particular period of time • Important to consider or establish background rate • One case of a rare occurrence or many episodes of a common occurrence can be an outbreak CDC. Principles of Epidemiology in Public Health Practice . 3rd ed. Updated 2012
  • 9. Epidemics and Clusters • Epidemic - same as outbreak but used for a wider geographic area • Cluster - aggregation of cases in a given area over a particular period without regard to whether the number of cases is more than expected; some are true outbreaks, some are sporadic and unrelated cases of the same or unrelated disease CDC. Principles of Epidemiology in Public Health Practice . 3rd ed. Updated 2012
  • 10. Exercise 1 • Which of the following situations can be an outbreak? A. Two adult patients with COPD develop pneumonia after admission to the general medical wards B. One patient in the surgical ward develops purulent discharge on the surgical incision site C. 10 postpartum women develop abdominal wound dehiscence after cesarean section within 2 weeks D. Two cases of varicella in the pediatric ICU within 5 days ✔ ✔
  • 11. Reasons for Investigating Outbreaks • Identify the source and control further transmission • Develop strategies to prevent future outbreaks • Evaluate existing prevention strategies • Describe new diseases and learn more about known diseases • Address public concern Reingold AL. Emerging Infectious Diseases 1998; 4 (1): 21-7.
  • 12. Investigating an Outbreak WHO, Infection Control. http://www.who.int/csr/bioriskreduction/infection_control/en/index.html Systematic planning and implementation of an outbreak investigation is necessary
  • 13. Outbreak Investigations: The 10-Step Approach 1. Identify investigation team and resources 2. Establish existence of an outbreak 3. Verify the diagnosis 4. Construct case definition 5. Find cases systematically and develop line listing 6. Perform descriptive epidemiology/develop hypotheses 7. Evaluate hypotheses/perform additional studies as necessary 8. Implement control measures 9. Communicate findings 10. Maintain surveillance
  • 14. 1. Identify the Investigation team and resources • Once an outbreak is suspected, notify appropriate individuals and departments in the institution (Chief of the affected service, head nurse of the unit, hospital administration) • Establish an Outbreak Investigation Team with clear delineation of responsibilities • Cooperation of various healthcare professionals is essential for efficient investigation and implementation of control measures • Identify available resources: personnel, supplies, laboratory
  • 15. Who should be part of the Outbreak Investigation Team? • Infection control staff must be part of the outbreak team. • Other members: – Local – Hospital Epi teams, microbiologist, other trained medical or clinical personnel – National - Disease Investigation Specialists; DOH-Epidemiology Bureau – Others – WHO, Philippine FDA
  • 16. 2. Confirmation of Outbreak • Confirm whether there is an outbreak by reviewing the following: – preliminary information on the number of potential cases – available microbiology – severity of the problem – demographic data of cases – place and time • Review definition of OUTBREAK
  • 17. 3. Verify the Diagnosis • Review existing data – Medical records/charts – Surveillance records – Microbiology – Other Laboratory reports and records • Interview unit medical/clinical personnel and paramedical staff • Clinical observations • Contact Hospital Epidemiologist & Infection Control team • Conduct clinical testing if needed
  • 18. 4. Construct Case Definition • Case definition is a set of standard criteria for classifying whether a person has a particular disease, syndrome, or other health condition. • Decide what constitutes a case, what you are looking for • Narrow enough to focus efforts but broad enough to catch all the cases • Define 3 essential characteristics of disease: Person, Place, Time • A gradient of definition based on level of evidence (as suspected, probable, or definite/confirmed case) is often helpful
  • 19. Case Definition • Use previously published, validated definitions if available and applicable – e.g. CDC/NHSN Surveillance Definitions for Specific Types of Infections 2017 • Where not available, use standardized written case definitions to ensure precise surveillance. • Use the same definitions for accurate and valid comparisons of data over time and across institutions
  • 20. CDC/NHSN 2017 Surveillance Definitions for Specific Types of Infections • Primary bloodstream infections (BSI): Laboratory- confirmed bloodstream infections (LCBI) that are not secondary to an infection at another body site • Central line-associated BSI (CLABSI): A laboratory-confirmed bloodstream infection (LCBI) where central line (CL) or umbilical catheter (UC) was in place for >2 calendar days on the date of event, with day of device placement being Day 1, AND the line was also in place on the date of event or the day before.
  • 21. CDC/NHSN 2017 Surveillance Definitions for Specific Types of Infections • Pneumonia (PNEU) - identified by using a combination of imaging (new or progressing abnormalities on chest imaging test), clinical(e.g. New onset or worsening purulent sputum or cough, or dyspnea or tachypnea and laboratory criteria (culture of blood/respiratory specimens or histopathologic test). • Ventilator-associated pneumonia (VAP): A pneumonia where the patient is on mechanical ventilation for >2 calendar days on the date of event, with day of ventilator placement being Day 1, AND the ventilator was in place on the date of event or the day before.
  • 22. CDC/NHSN 2017 Surveillance Definitions for Specific Types of Infections • Non-Catheter-associated Urinary Tract Infection (Non-CAUTI) - Patient has at least one of the ff: fever, suprapubic tenderness, costovertebral angle pain or tenderness, urinary frequency, urinary urgency, dysuria AND has a urine culture with no more than two species of organisms identified, one of which is a bacterium of ≥105 CFU/ml. • Catheter-associated UTI (CAUTI): A UTI where an indwelling urinary catheter was in place for >2 days or the day before AND patient has clinical signs and symptoms of UTI AND has a urine culture with no more than two species of organisms identified, one of which is a bacterium of ≥105 CFU/ml.
  • 23. Sample Case Definition: Outbreak of Hospital-acquired Pneumonia Person Place Time Components of Case Definition Hospital-acquired Pneumonia • Occurring after admission to ward A • During May-August 2016 • New/progressing abnormalities on chest imaging test AND new onset or worsening purulent sputum/cough, or dyspnea or tachypnea AND positive culture of blood or resp. specimens
  • 24. 5. Find cases systematically and develop line listing • How do you find cases? – Microbiology data – Infection control or surveillance records – Discussions with clinicians – Pharmacy records – Medical records – Nursing charts – Pathology reports
  • 25. Develop Line Lists • Line list - used to summarize information • What to put on a Line List – Demographic information (age, sex, occupation, hospital numbr, date of admission, date of surgery, etc) – Clinical Data: Signs and Symptoms, Onset dates and/or times, Outcomes, Lab results, Antimicrobials, other Medications – Exposure information : procedures or surgery; medical devices or equipment – Other potentially relevant data
  • 26. Sample Line List from an Investigation of Acute gastroenteritis
  • 27. • Don’t get bogged down with case definitions and capturing all cases • Goal of Outbreak investigation is NOT to find and describe every case • Goal is to STOP THE OUTBREAK – do not need to find every case
  • 28. 6. Perform Descriptive epidemiology and develop hypotheses • Examine the distribution of a disease in a specific or defined population (“at-risk population”) • Describe the basic features of its distribution in terms of Person, Place, Time • Assess Time-trend: Point source, propagated or circulating, recurrent or cyclical, seasonal, combination • Conduct surveillance
  • 29. Surveillance • Defined as: “The ongoing, systematic collection, analysis, interpretation, and dissemination of data regarding a health- related event for use in public health action to reduce morbidity and mortality and to improve health.’’ • Basic components of a surveillance system: – Data collection – Procedure for evaluating data and making comparisons – A means for disseminating the results Centers for Disease Control and Prevention. Updated guidelines for evaluating public health surveillance systems: recommendations from the guidelines working group. MMWR 2001;50:1-35.
  • 30. Retrospective Surveillance • Retrospective surveillance – Comprehensive review of sequential events in the medical records and examination of information even after patient is discharged – Avoids time-consuming efforts of locating and reviewing charts – Disadvantage: does not permit interactions with ongoing caregivers or verifying data collected
  • 31. Active Surveillance • Prevalence study (Cross-sectional study) – Identify all patients with HAI hospitalized at a given point time in the entire hospital, or on selected units. – Useful for conducting initial assessment of current issues, before proceeding to a more focused continuing active surveillance programme. – Outcome measure is a Prevalence Rate.
  • 32. Active Surveillance • Incidence study (Prospective, longitudinal) – Detect new cases during the surveillance period – Preferable if data can be collected regularly and patient is still under the care of the institution – Able to capture information in real time, interview patient’s caregivers, interactively obtain or observe findings that may not be recorded in the patient record – More effective in detecting differences in infection rates, to follow trends, to link infections to risk factors, and for inter-hospital and inter-unit comparisons – Outcome measure are Incidence rates, Attack rates, and Infection ratio
  • 33. Prevalence Study (Cross-sectional study) Patient A Patient B Patient C Patient D Patient E Patient F Patient G Patient H Point Prevalence- assess only HAIs active on the day of the survey 7 days Period Prevalence- include HAIs active on the day of the survey and those active during a predefined period before the survey day
  • 34. Exercise: Compute HAI Prevalence rate Patient A Patient B Patient C Patient D Patient E Patient F Patient G Patient H 7 days Point Prevalence 2/8 (25% ) Period Prevalence 5/8 (62.5%)
  • 35. Incidence Study (Prospective) Patient A Patient B Patient C Patient D Patient E Patient F Patient G Patient H Incidence of HAI 2/8 (25%) 4 weeks
  • 36. Epidemic Curves • Graph used to depict the time course of an outbreak or epidemic • Provides a simple visual display of the outbreak's magnitude and time trend • Graphs the number of cases by date or time of onset of illness. • Suggests type of exposure or time of exposure
  • 37. Time of Exposure is Possible if Agent is known Zack Moore, MD, MPH, Medical Epidemiologist. North Carolina Division of Public Health
  • 38. Zack Moore, MD, MPH, Medical Epidemiologist. North Carolina Division of Public Health Possible Agent can be Identified if Exposure Time is known
  • 41. Environmental Sampling • Vital part of investigation • Should be done with (not instead of) epidemiologic investigation • Ideally, epidemiologic results guide sample collection – should not be taken randomly • Can support epidemiologic findings • Positive or negative results can be misleading or difficult to interpret (consider contamination) • Understand limitations Environmental and personnel culturing should NOT be the first step in any outbreak investigation!
  • 42. Calculation of HAI Rates • The frequency of infection can be estimated by prevalence and incidence rates • Rates are obtained by dividing a numerator by a denominator • Numerator - event of interest which can be: – number of infections – number of infected patients observed • Denominator - can be any of the following: – Total population in which the event may occur (at-risk population) – Number of patient-days of risk Ducel G et al. Prevention of hospital-acquired infections. A practical guide. WHO Geneva 2002.
  • 43. Ways to Calculate HAI Rate • Prevalence rate (%) – Number of patients with HAI (total or specific infection) at the time of study divided by Total number of patients observed or exposed at the same time X100 • Cumulative Incidence rate (Attack rate) – Number of new infections acquired in a period divided by Total number of patients observed or exposed at the same time X100 Lee TB et al. . Recommended practices for surveillance: APIC,Inc.Am J Infect Control 2007;35:427-40; Ducel G et al. Prevention of hospital-acquired infections. A practical guide. WHO Geneva 2002 .
  • 44. Ways to Calculate HAI Rate • Risk Adjusted Infection Rates – rates are expressed in terms of specific exposures rather than using an overall census denominator. – Incidence rate PER PATIENT-DAYS: number of new HAI pooled throughout the month(s) divided by the patient-days of stay x 1000 – Incidence rate PER DEVISE DAYS: number of new HAI pooled throughout the month(s) divided by the device-days x 1000 (e.g. catheter days) Lee TB et al. . Recommended practices for surveillance: APIC,Inc.Am J Infect Control 2007;35:427-40; Ducel G et al. Prevention of hospital-acquired infections. A practical guide. WHO Geneva 2002 .
  • 45. Exercises Calculate the Surveillance rate for the following: 6.2 1. Nosocomial sepsis rate (Prevalence rate) No. of At-risk patients in one month (newly admitted patients + patients carried over from previous month) No. of sepsis cases Prevalence Rate (%) (no. of sepsis cases ÷ no. at-risk patients) 242 15 1.6 2. Procedure-specific SSI rate (Incidence rate) No. of cesarean section operations in one month Total No. of New Skin/Soft tissue infection Incidence Rate (%) (no. of new SSI ÷ no. of cesarean sec performed) 122 2
  • 46. Exercises 4. Ventilator-associated pneumonia rate (Incidence rate per device days) No. of ventilator days in pediatric ICU No. of ventilator- associated pneumonias in pediatric ICU Rate per 1000 ventilator days (no. of ventilator-associated pneumonias ÷ no. of ventilator days x 1000) 801 5 Calculate the Surveillance rate for the following: 6.2 3. Urinary tract Infection (Incidence rate per patient-days) Total patients-days of stay during specified time period) No. of UTI cases Rate per 1000 patient- days (number of UTI ÷ total patient-days x 1000) 989 11 11.1
  • 47. Hypothesis Formulation • Formulate hypothesis to explain the observed increase in incidence • Look into associations • Formulate a hypothesis on the type of infection (exogenous, endogenous) • Tentatively identify the source and route of infection
  • 48. 7. Evaluate hypotheses and perform additional studies as necessary • Test hypothesis about the relationship of a disease to a specific cause • Determine Cause-effect relationship by conducting an epidemiologic study that relates the exposure of interest to the outcome of interest • Typical study designs: cohort, case-control, experimental design • Determine the appropriate approach to surveillance depending on the issue being surveyed and available resources
  • 49. Analytical Epidemiologic Studies • Cohort Studies (prospective or retrospective) – Include everyone who could have been exposed – A cohort study is feasible only when the population is well defined and can be followed over a period of time. • Case-Control Studies (retrospective) – Compare exposures among ill persons (case- patients) and non-ill persons (controls)
  • 50. Sample Study: Cohort Risk Ratio = Risk in exposed group/ Risk in unexposed group Calculation: [a/a+b) ÷ c/c+d] Ex. (25/53) ÷ (2/28) = 0.47/0.07 = 6.7 Interpretation: Exposed persons were 6.7x more likely to develop HAI than those unexposed HAI Cases No HAI (Control) total Exposure 25 (a) 28 (b) 53 No exposure 2 (c) 26 (d) 28 Total 27 54 81
  • 51. Sample Study: Case-Control Odds Ratio: (No. exposed cases x No.unexposed controls) divided by (No. exposed controls x No.unexposed cases) Calculation: [ad/ bc] Example: 25x26/28 x 2 = = 650/56 = 11.6 Interpretation : Persons exposed had 11.6 times the odds of developing HAI than persons not exposed HAI Cases No HAI (Control) total Exposure 25 (a) 28 (b) 53 No exposure 2 (c) 26 (d) 28 Total 27 54 81
  • 52. Analytic Studies • Can be useful for supporting your hypothesis if no obvious source identified • Not always necessary • Time consuming and challenging • Small number of cases limits power
  • 53. 8. Implement control measures • Implement control measures to control the outbreak • Can occur at any point during outbreak • Isolation, cohorting, drug or product recall • Balance between preventing further disease and protecting credibility and reputation of institution • Should be guided by epidemiologic results in conjunction with environmental investigation
  • 54. Break the Chain of Infection … stop the spread of Infectious diseases
  • 55. Hepatitis C Outbreak in Nevada Endoscopy Center, 2008 • Potentially exposed > 50,000 patients to Hepatitis C and other infectious diseases; 8 acute hepatitis C cases linked directly, 10 hepatitis C cases possibly linked • Identified breaches contributed to transmission: – Reuse of syringes for more than one patient – Reuse of single use vials of propofol for multiple patients – Poor hand hygiene practices MMWR May 16, 2008 / 57(19);513-7
  • 56. General Infection Control Practices that Prevent Nosocomial Infections • Hand hygiene • Standard (universal) precautions • Isolation precautions : contact, droplet, and airborne spread • Environmental cleaning and disinfection • Disinfection and sterilization of medical devices and patient care equipment • Enhanced healthcare provider education and training • Cohorting patients or staff • Maintain adequate staffing levels Siegel JD, et al. HICPAC 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, June 2007 ; Pittet D, et al Lancet Infect Dis 2006; 6:641.; Haley RW et al. Am J Epidemiol 1985; 121:182.; Whitehouse JD et al.. Compr Ther 1998; 24:71.
  • 57. Sample Control measures for Outbreak Management Ducel G et al. Prevention of hospital-acquired infections. A practical guide. WHO Geneva 2002
  • 58. 9. Communicate findings • During the investigation of an outbreak, timely, up-to-date information must be communicated to the hospital administration, department or unit, and in some cases, to the public. • Develop a means for disseminating the results to those who have a need to know (those involved in improving those outcomes). • Include measures to prevent such outbreaks in the future. • Media attention desirable if public action needed
  • 59. Write the Final Report • A final report on the outbreak investigation should be prepared • It should describe the outbreak, interventions, and effectiveness, and summarize the contribution of each team member participating in the investigation. • It should also make recommendations to prevent future occurrence. • This report can be in the medical literature, and may be considered as a legal document.
  • 60. 10. Maintain surveillance • Follow-up investigation to determine if there are additional case-patients • Decide if outbreak is over • Document effectiveness of control measures • Determine if the outbreak has spread outside its original area or the area where the interventions were targeted.
  • 62. Example of a Hospital Outbreak Investigation • March 25, 2017, a report was received that there were 12 cases of neonatal sepsis in the Neonatal intensive Care Unit (NICU). • The first case was reported on March 4: Klebsiella pneumoniae was isolated from a preterm baby with severe respiratory distress. • Within a period of three weeks from the day the first case was reported, 11 neonates developed culture proven K. pneumoniae septicemia. • Nine of the 12 (7 male, 5 female) septicemic neonates were preterm (75% preterm), 3 were fullterm.
  • 63. Example #1 • First clinical manifestation occurred at a mean of 4.8 + 0.43 days after admission (range 3-10days). • Main presenting complaint: respiratory distress associated with lethargy and feeding difficulties. • Disseminated intravascular coagulation (DIC) seen in 6 neonates • Necrotizing enterocolitis (NEC) seen in 3 neonates • Deaths: 10 deaths due to septic shock (83%).
  • 64. Outbreak Investigations: The 10-Step Approach 1. Identify investigation team and resources 2. Establish existence of an outbreak 3. Verify the diagnosis 4. Construct case definition 5. Find cases systematically and develop line listing 6. Perform descriptive epidemiology/develop hypotheses 7. Evaluate hypotheses/perform additional studies as necessary 8. Implement control measures 9. Communicate findings 10. Maintain surveillance
  • 65. Is there an Outbreak? Month Total No. of NICU patients No. of HCAI HCAI nosocomial) infection) Rate January 2017 148 6 4.05% February 2017 145 4 2.75% March 2017 150 12 8.0%
  • 66. Outbreak Investigations: The 10-Step Approach 1. Identify investigation team and resources 2. Establish existence of an outbreak 3. Verify the diagnosis 4. Construct case definition
  • 67. Verify the diagnosis • Review existing data – Medical records/charts – Surveillance records – Microbiology – Other Laboratory reports and records • Interview unit medical/clinical personnel and paramedical staff • Clinical observations
  • 68. Case Definition: Outbreak of Sepsis (Bloodstream Infection) Person Place • Patient ≤ 1 year of age has at least one of the ff SSx : fever (>38.0oC), hypothermia (<36.0oC), apnea, or bradycardia AND K. pneumoniae identified from blood is not related to an infection at another site Time Components of Case Definition Lab-Confirmed Bloodstream Infection Criteria (LCBI) • Occurring after admission to the NICU • During March 1-31, 2017
  • 69. Outbreak Investigations: The 10-Step Approach 1. Identify investigation team and resources 2. Establish existence of an outbreak 3. Verify the diagnosis 4. Construct case definition 5. Find cases systematically and develop line listing
  • 70. Example #1: List of Patients with Klebsiella pneumoniae Nosocomial Sepsis Px AOG DOB Date of onset Umbilic cannula Mech. Vent NGT NEC DIC Died 1 Preterm 2/25/17 3/4/17 Y N Y Y N N 2 Fullterm 2/27/17 3/8/17 Y N N N Y Y 3 Fullterm 2/28/17 3/8/17 Y N N N N N 4 Preterm 2/28/17 3/10/17 Y Y Y N N Y 5 Preterm 2/28/17 3/10/17 N Y N N N Y 6 Preterm 3/3/17 3/10/17 Y Y N N N Y 7 Preterm 3/5/17 3/12/17 Y Y N N N Y 8 Fullterm 3/6/17 3/12/17 N N N N Y N 9 Preterm 3/9/17 3/14/17 Y Y N N Y Y 10 Preterm 3/20/17 3/24/17 Y Y N N Y Y 11 Preterm 3/21/17 3/25/17 Y Y N Y Y Y 12 Preterm 3/22/17 3/25/17 Y Y N Y Y Y
  • 71. Outbreak Investigations: The 10-Step Approach 1. Identify investigation team and resources 2. Establish existence of an outbreak 3. Verify the diagnosis 4. Construct case definition 5. Find cases systematically and develop line listing 6. Perform descriptive epidemiology/develop hypotheses
  • 72. Example #1: Epi Curve of NICU Outbreak Point Source Epidemic curve – suggests same source over a relatively brief period
  • 73. What do we know about Klebsiella pneumoniae sepsis? • Klebsiella pneumoniae has been incriminated in hospital acquired infections. • This organism colonizes the bowel and skin and is probably transmitted via medical staff hands. • Nosocomial K. pneumoniae infection is associated with a high mortality in neonates and antimicrobial therapy in infections has been complicated by the emergence of multi-resistant strains.
  • 74. Example #1: NICU admissions and staffing • Average number of monthly NICU admissions: 145 (range 135 – 155) • At any one time, there are 12-20 neonates requiring mechanical ventilation • Nurse staffing has always been a problem, as shown below: Level of Care Nurse-to-patient Ratio Actual Optimal* Newborns requiring only routine care 1:12-15 1:6- 8 Newborns in transition/ req close observation 1:6-8 1:4 Newborns requiring intermediate care 1:6-8 1: 2-3 Newborns requiring intensive care 1:4 1: 1-2 *AAP and American College of Obstetricians Gynecologists. (2012). Guidelines for Perinatal Care, 7th Edition. Elk Grove Village, IL; National Association of Neonatal Nurses. Position Statement #3009. Minimum RN Staffing in NICUs. Revised July 2008.
  • 75. Example #1: Environmental Surveillance Culture Results • Environmental surveillance cultures identified the isolates to be the following: Bacterial Isolate Location Klebsiella pneumoniae Ventilator tubings and rinsing bottles 2 out of 6 sinks sampled in the high risk area Coagulase negative Staphylococcus 2 Feeding cups out of 10 sampled Enterobacter sp. 1 incubator out of 10 in the high risk area
  • 76. Example #1: Hypothesis on Possible Sources of Infection Potential exposure or Source Examples Contaminated Medical Device ventilator tubings, suction tubings. Intravascular lines (central or peripheral), umbilical cannula Contaminated patient care materials or equipment Drugs, IV fluids, thermometers, breastmilk collection and storage equipment, feeding bottles or feeding cups; malfunction of disinfection /sterilization machines Improper Procedures or techniques Improper handwashing and hand hygiene procedures; Inadequate aseptic techniques in intubation, suctioning, etc; Environment inadequate or improper cleaning and disinfection/sterilization ; contaminated or ineffective disinfectants Staffing High nurse-to-patient ratio; crossing of nurses between ‘clean” and “infected” areas Others Contaminated breastmilk Others?
  • 77. Outbreak Investigations: The 10-Step Approach 1. Identify investigation team and resources 2. Establish existence of an outbreak 3. Verify the diagnosis 4. Construct case definition 5. Find cases systematically and develop line listing 6. Perform descriptive epidemiology/develop hypotheses 7. Evaluate hypotheses/perform additional studies as necessary 8. Implement control measures
  • 78. Case #1: What are the Infection Control Measures recommended to control this outbreak? Recomendations Yes or No Hand hygiene Standard (universal) precaution Isolation precautions : contact, droplet, and airborne spread Environmental cleaning and disinfection Disinfection and sterilization of medical devices and patient care equipment Enhanced healthcare provider education and training Cohorting patients Maintain adequate staffing levels Others: e.g. Closing of unit Ye s Ye s Ye s Ye s Ye s Ye s Ye s Ye s Ye s
  • 79. Outbreak Investigations: The 10-Step Approach 1. Identify investigation team and resources 2. Establish existence of an outbreak 3. Verify the diagnosis 4. Construct case definition 5. Find cases systematically and develop line listing 6. Perform descriptive epidemiology/develop hypotheses 7. Evaluate hypotheses/perform additional studies as necessary 8. Implement control measures 9. Communicate findings 10. Maintain surveillance
  • 80. Important Points • Epidemiologic investigations are essential to determine source of outbreaks • Be systematic, consider each step • Follow the steps if appropriate • Multiple steps may happen at once • Might need to repeat steps