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Ask The Expert Series Dr. Hudson Garrett Jr
You ask an excellent question about national benchmarks. Currently, the data specific to LTC Infection Prevention is limited, however this is rapidly changing with CDC’s push to move LTCFs to use the CDC National Healthcare Safety Network Data (NHSN). The current data for HAIs in LTCFs is quite old and very outdated, therefore I would not recommend that you cite it.
As you can see on the NHSN website, CDC is aggressively tracking the following national data points:
- Hand Hygiene
- Vaccination Compliance
- Urinary Tract Infections
- MDROs/Clostridium difficile (Clostridium difficile, MRSA, and other Drug-Resistant Infections)
More information on enrollment and national surveillance is available here: http://www.cdc.gov/nhsn/ltc/index.html.
Once more facilities enroll in NHSN, we will have better and more accurate data on national estimates of HAIs across the post-acute care continuum of care.
If I can be of any further assistance, please do not hesitate to let me know. If there are specific data needs that you have, I would be happy to help you locate the best source. I am actually meeting with the head of the CDC Healthcare Division tonight for something else, and can check on any additional specific needs that you might have.
Centers for Medicare and Medicaid Services Releases New Guidance on Long Term Care Infection Prevention and Control Program
The Centers for Medicare and Medicaid Services (CMS) has released a new rule which specifically addresses the evolving needs of Infection Prevention and Control Program (IPCP) in Long-Term Care Facilities (LTCFs). This rule, which is named the Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care Facilities, is scheduled for implementation on November 28, 2016 and components will be phased in through three unique stages, the last completing in November 2019. Here are a few highlights of the new rule that impact the IPCP that nursing leaders must be aware of:
- Facilities must develop and Infection Prevention and Control Program that includes an Antibiotic Stewardship Program and designate at least one Infection Preventionist.
- The Infection Prevention and Control Officer (IPCO) must conduct an annual facility assessment specific to Infection Prevention and Control. The IPCO is not required to be a registered nurse. The individual must have specific training in infection prevention and control beyond their professional degree.
- The IPCO must participate on the QAA Committee.
- The IPCP must include a focus on prevention of the transmission of communicable diseases as well as infections. These efforts should focus on all residents, staff. Volunteers, visitors, and other individuals providing services under a contractual arrangement.
- The IPCP must have written policies and procedures and surveillance systems in place to identify possible communicable diseases or infections before they can spread to other persons in the facility.
- Staff must be thoroughly trained in the IPCP.
- The Infection Prevention and Control Officer just received specialized training in infection prevention and control beyond their initial professional degree. Their primary responsibility should be the administration of the infection prevention and control program.
- Based on the needs of the IPCP, the facility must determine the resources it needs to devote to its infection control program.
As identified in the newly released rule, CMS is ensuring that all residents and patients in LTCFs benefit from a comprehensive and well-resourced Infection Prevention and Control Program. While resources are in many instances a struggles in LTCFs, it is important to have strategic conversations with Executive Leadership regarding the necessary resources for implementation of the Infection Prevention and Control Program based on the facility’s needs assessment.
To learn more about NADONA’s Infection Preventionist Board Certification, please visit: https://www.nadona.org/product/infection-prev-ip-bc-certification/. NADONA also offers a host of continuing education
- Hudson Garrett Jr., PhD, MSN, MPH, FNP-BC, PLNC, VA-BC, GDCN, IP-BC, CDONA, FACDONA
Chief Clinical Officer
The Director: Journal of the National Association of Directors of Nursing Administration/LTC
Global Chief Clinical Officer
Zika can be sexually transmitted from a person who has Zika to his or her sex partners, even while they are not symptomatic. Sex includes vaginal, anal and oral sex, and the sharing of sex toys. To prevent sexually transmitted Zika, CDC recommends that:
- All pregnant women with sex partners who live in or traveled to an area with Zika use barrier methods during sex or abstain from sex for the remainder of their pregnancy.
- All other couples in which a partner has been in an area with Zika can also reduce the risk of sexual transmission by using barrier methods or abstaining from sex.
- Barriers include male and female condoms and dental dams
- To be effective, barrier methods must be used from start to finish, every time during vaginal, anal and oral sex.
Health care providers should:
- Test all pregnant women who may have been exposed to Zika sexually (i.e., had sexual contact without a barrier method with a person who lives in or has traveled to an area with Zika).
- Test any patients for Zika if they develop symptoms of Zika and report potential sexual exposure to a partner who lives in or traveled to an area with Zika.
Latest Changes: The new guidance expands CDC’s recommendations for the prevention of sexually transmitted Zika virus to include the possibility of sexual transmission from an infected woman. It expands CDC’s definition of sexual exposure to Zika to include sex without a barrier to protect against infection (including male or female condoms, among other methods) with any person — male or female — who has traveled to or lives in an area with Zika.
- UPDATE: Interim Guidance for Prevention of Sexual Transmission of Zika Virus – United States, July 2016 (MMWR, Jul. 25, 2016)
- Interim Guidance for Prevention of Sexual Transmission of Zika Virus – United States, 2016 (Mar. 25, 2016)
- Interim Guidelines for Prevention of Sexual Transmission of Zika Virus – United States, 2016 (Feb. 12, 2016)
Questions & Answers
What kind of sexual activity puts someone at risk for Zika if their partner is infected?
A person with Zika can transmit the virus to his or her partner(s) through vaginal, anal, and oral sex. The sharing of sex toys may also put someone at risk. Zika has been detected in semen, vaginal fluids, saliva, urine, and breast milk. There is no evidence at present that Zika can be transmitted through saliva during deep kissing.
There is documented evidence of sexual transmission of Zika from male-to-female, male-to-male and female-to-male sex partners. Female-to-female sexual transmission has not yet been reported but it is biologically plausible.
Are infections of same-sex partners being identified?
To date, there has been one case of male-to-male sexual transmission in the United States; none of the confirmed cases of sexual transmission have been female-to-female. However, other STDs can be passed between female sex partners, so it would not be unexpected to eventually have such a case documented. Women with Zika may pass the virus to sex partners through vaginal fluids or menstrual blood.
The use of barrier methods or abstinence are recommended to protect sex partners concerned about Zika. The partners of individuals who live in or traveled to areas with Zika should be tested if they had sex without using a barrier method and develop symptoms of Zika.
Can asymptomatically infected people have Zika in genital secretions and transmit it to their sex partners?
Definitive evidence of sexual transmission from an asymptomatically infected person has not been confirmed. But there is at least one case report of suspected sexual transmission from an asymptomatically infected man, who had Zika detected in semen at 39 days after he left the area with widespread Zika virus transmission. People who develop symptomatic illness have transmitted Zika before they had symptoms, while they had symptoms, and after symptoms resolved.
Studies are underway to help us better understand when and under what circumstances Zika can be transmitted sexually. Specifically, scientists are studying semen and vaginal secretions to understand the incidence of viral shedding, the concentrations of virus, and the duration and pattern (e.g., steady decline, intermittent on/off) of viral shedding in genital secretions.
How long can Zika be transmitted to sex partners after initial infection?
Our knowledge is growing rapidly but we don’t yet know exactly how long infected people can transmit Zika sexually. Available data are currently limited to case reports and we will have more information from studies that are underway. Detection of Zika virus RNA in semen has been reported up to 93 days after illness onset. Current evidence suggests that Zika virus persists longer in semen than in other body fluids, including vaginal fluids, urine, and blood. CDC therefore recommends that non-pregnant couples consider using barrier methods or abstaining from sex for at least 8 weeks after illness onset if a female partner is diagnosed with or experiences symptoms of Zika, and for at least 6 months if a male partner is diagnosed with or experiences symptoms of Zika. The longer precautionary period recommended for men with Zika takes into consideration the fact that Zika can persist in the semen of infected men after they have recovered from illness. Ongoing studies are systematically examining the incidence and duration of Zika virus shedding in the genital secretions of people with both symptomatic and asymptomatic Zika infection.
How common is it for a man or woman to transmit Zika to their sex partners?
We do not know. CDC is conducting a study of men and women infected with Zika to better understand how often different body fluids, including semen and vaginal fluids, can transmit Zika. To date, the majority of documented cases of sexually transmitted Zika infection have been from men to their sex partners. The limited number of cases of sexual transmission from women to their sex partners suggests that it can occur but is less frequent than sexual transmission of Zika from men. It would not be unexpected to see more cases of sexual transmission from women to their sex partners, but at this time CDC expects most cases will continue to be reported from men to their female and male sex partners. None of the confirmed cases of sexual transmission have been female-to-female. However, other STDs can be passed between female sex partners and it would not be unexpected to eventually have such a case documented. Women with Zika may pass the virus to sex partners through vaginal fluids or menstrual blood.
Should people who have been in areas with Zika take precautions to prevent sexual Zika transmission to their partners?
Yes, especially if their partner is pregnant. Zika virus infection during pregnancy can cause microcephaly and other severe fetal nervous system defects.
Men and women who have traveled to or live in an area of active Zika transmission and who have a pregnant sex partner should use a barrier method every time they have vaginal, anal, or oral sex, or abstain from sex for the duration of the pregnancy. They should also avoid sharing sex toys throughout the pregnancy. This is important even for those who are asymptomatic. Most people who are infected do not have symptoms and it is possible that an asymptomatic person can transmit Zika through sex.
Men and women who have traveled to or live in an area of active Zika transmission and who have partners who are not pregnant can also use barrier methods consistently and correctly or not have sex, if they are concerned about sexually transmitting Zika. The recommended length of time for using barrier methods or not having sex will depend on the person’s gender, whether s/he experiences clinical illness compatible with Zika or has been diagnosed with Zika, and where s/he lives. Individuals considering use of barrier methods or abstinence should weigh the personal risks and benefits, which include:
What should I tell patients concerned about getting Zika through sex?
Only people with sex partners who traveled to or live in an area with Zika are at risk for getting Zika virus through sex. Sexual transmission of Zika is of greatest concern for pregnant women with partners who have had, or are at risk for, Zika virus infection.
To be effective, barrier methods must be used correctly from start to finish, every time during vaginal, anal, and oral sex.
When is Zika testing recommended to identify possible sexual transmission cases?
Zika virus testing is recommended for people who may have been exposed to Zika through sex and who have Zika virus symptoms. Testing is also recommended for a pregnant woman with possible sexual exposure to Zika virus if either she or her partner develops one or more symptoms of Zika.
At this time, testing a person’s blood, urine, or genital secretions to determine their potential risk of sexually transmitting Zika virus is not recommended for the following reasons:
First, a negative blood test or antibody test could be falsely reassuring. This can happen when:
Second, we currently have limited understanding of Zika virus shedding in genital secretions, or of how to interpret the results of tests of semen or vaginal fluids. Zika shedding in these secretions may be intermittent, in which case a person could test negative at one point but still carry the virus and shed it again in the future. Studies are underway to better understand the pattern of Zika shedding in genital secretions.
For more information on diagnostic testing for Zika, see Testing for Zika(http://www.cdc.gov/zika/hc-providers/testing-for-zikavirus.html).
What is the role for STD/HIV Programs in the Zika response?
STD and HIV programs have expertise in patient education, communication, and condom promotion and distribution efforts that may be relevant to preventing sexual transmission of Zika virus. CDC encourages state and local programs to work with their state health officials and connect concerned STD/HIV clients with possible sexual exposure to Zika to primary care or reproductive health providers who can offer counseling and follow up.
National Quality Forum Releases New Playbook for Antibiotic Stewardship
Antibiotics are powerful drugs to treat serious infections. However, decades of overprescribing and misuse have resulted in bacteria that are increasingly resistant to these potent drugs, creating a growing threat of new superbugs that are difficult, and sometimes even impossible, to treat. According to the Centers for Disease Control and Prevention (CDC), drug-resistant bacteria cause two million illnesses and 23,000 deaths annually. National Quality Forum’s National Quality Partners (NQP) convened more than 25 experts and national stakeholders from the public and private sectors—including patient advocates, infectious disease physicians and pharmacists, and acute-care providers—to develop National Quality Partners Playbook: Antibiotic Stewardship in Acute Care. The Playbook is designed to help hospitals and health systems strengthen existing antibiotic stewardship initiatives or create antibiotic stewardship programs from the ground up. Based on CDC’s Core Elements of Hospital Antibiotic Stewardship Programs, NQP’s Playbook offers practical strategies for implementing high-quality antibiotic stewardship programs in hospitals nationwide.
To download the playbook, visit the National Quality Forum: click here or here
Dr. Hudson Garrett Jr.
Author: J. Hudson Garrett Jr., PhD, MSN, MPH, FNP-BC, PLNC, VA-BC™, CDONA, IP-BC, FACDONA
Editor-in-Chief The Director: Journal of the National Association of Directors of Nursing Administration in Long Term Care Master Trainer
Post-acute care settings such as skilled nursing facilities, long-term acute care hospitals (LTACHs) and acute inpatient rehabilitation facilities (IRFs) cater to an increasingly complex patient population transitioning out of the hospital, but still requiring significant care and support. Many of these individuals receive this care in a residential setting to foster social interactions and communal activities as part of the rehabilitation process. These special circumstances can make traditional infection prevention and control interventions difficult to implement. For example, in nursing homes, which provide a mixture of skilled nursing care and residential care, studies have estimated that 1 to 3 million serious healthcare-associated infections (HAIs) occur every year resulting in hospitalizations and associated mortality and morbidity.
Individuals receiving care in long-term care facilities, such as nursing homes and assisted living facilities, have unique challenges related to infection control. Luckily, there are evidence-based strategies to reduce infections in these patients. Basic interventions such as hand hygiene, maintaining a clean environment of care, safe injection practices, properly using personal protective equipment, and implementing a robust antibiotic stewardship program will dramatically reduce the risk of HAIs for these patients.
Specific data on the incidence of HAIs in post-acute care settings is currently limited to LTACHs and IRFs even though significantly more patients receive care in skilled nursing facilities. Participation in CDC’s National Healthcare Safety Network by skilled nursing facilities is crucial so we can better understand the impact and trends associated with HAIs in long-term care environments. These data provide useful tools to target infections and improve compliance with established evidence-based practices.
Infection preventionists and nursing leaders must work collaboratively across disciplines and partner with environmental services professionals and technicians, medical laboratory personnel, and clinical/consulting pharmacists to reduce HAIs. Sharing data and best practices along with championing HAI reduction initiatives will not only help reduce HAI rates, but more importantly, create a culture for sustained efforts to each Zero! One timely example of collaboration is improving antibiotic stewardship across the entire continuum of care. This requires interprofessional collaboration between both healthcare facilities (i.e. acute care hospitals and post-acute care facilities), providers, clinicians, and public health partners. Only through collaboration and a relentless focus on improving stewardship will healthcare benefit from the stewardship efforts. These focused efforts also will assist in reducing other HAI targets such as Clostridium difficile infections.
For more information about infection prevention and control training and certification related to Post Acute/Long-term Care Settings, please visit www.nadona.org. The 2016 NADONA Annual Educational Conference will feature multiple sessions dedicated specifically to improving infection prevention and control across post-acute care settings, as well as a special preconference session on infection prevention and control for all healthcare professionals.
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In an effort to keep you informed about the ongoing Elizabethkingia outbreak currently taking place, NADONA is providing this clinical information update about the current outbreak which is being investigated by the Centers for Disease Control and Prevention.
Elizabethkingia is a genus of bacteria commonly found in the environment worldwide and has been detected in soil, river water and reservoirs. However, it rarely makes people sick. Cases are diagnosed through culture of body fluids, most often blood testing. Elizabethkingia has mostly caused meningitis in newborn babies and meningitis or bloodstream and respiratory infections in people with weakened immune systems. About 5-10 cases per state per year are reported in the United States, with a few small, localized outbreaks reported in both the US and other countries, usually in healthcare settings.
Epidemiology and Transmission
Elizabethkingia are Gram-negative bacteria that tend to be naturally resistant to many of the antibiotics that physicians may typically use to treat infections. However, the strain responsible for most of the cases in the current outbreak can be treated with several other antibiotics, so early recognition of the bacteria is critical to ensure patients receive appropriate diagnosis and treatment.
Confirmation of the species Elizabethkingia anophelis and determination whether cases are part of the ongoing outbreak is done through MALDI-TOF (which detects the protein fingerprints of a microbe) and optical mapping at CDC.
Elizabethkingia are opportunistic pathogens preferentially causing illness among immune compromised individuals or patients with underlying medical conditions, and are associated with high mortality. Therefore, early detection and treatment with an effective antibiotic regimen is important to increase the probability of good outcomes. The index of suspicion for Elizabethkingia infections should be high among patients with multiple co-morbid conditions, particularly malignancy, diabetes mellitus, chronic renal disease or end-stage renal disease on dialysis.
In this outbreak, the bacteria primarily infect older adults and those who have serious underlying health conditions. The infection typically presents as septicemia and can be deadly if not treated early with appropriate antibiotics. (The fatality rate in the current outbreak is about 30%.) Clinicians who have patients with underlying health issues and bloodstream infections of unknown etiology should consider Elizabethkingia as a possible cause.
Diagnosis and Testing
Diagnosis is made on the basis of results of culture from sterile sites, most often blood. However, owing to its rarity, some clinical laboratories use bacterial detection software that may misidentify Elizabethkingia as other bacteria. Therefore, if results come back as Flavobacterium meningosepticum or Chryseobacterium meningosepticum, CDC advises clinicians to report these results to the state health department for consultation, and to treat presumptively as E anophelis.
Infection Control Measures
Healthcare professionals should follow the Centers for Disease Control and Prevention Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings and CDC Guideline for Management of Multidrug-Resistant Organisms in Healthcare Settings. Patients with Elizabethkingia infection should be placed on contact precautions out of an abundance of caution. For more information on the CDC Guidelines, please visit: http://www.cdc.gov/hicpac/pubs.html.
Even though this bacterium is resistant to many antimicrobials used to treat gram-negative rod bloodstream infections, Wisconsin clinical microbiology laboratories, along with CDC, have identified that the strains responsible for most cases in the current outbreak are susceptible to several antibiotics. These include fluoroquinolones, rifampin, minocycline, and trimethoprim/sulfamethoxazole. If possible, combination treatment is recommended over monotherapy. For best results, treatment should be selected based on antimicrobial susceptibility testing results for each suspected case.
For more information, visit please the Centers for Disease Control and Prevention Elizabethkingia Outbreaks website: http://www.cdc.gov/elizabethkingia/outbreaks/index.html.
Hudson Garrett Jr., PhD, MSN, MPH, FNP-BC, PLNC, CDONA, CADDCT, CDP, CALN, GDCN, FAAPM, VA-BC™, IP-BC, FACDONA
The Director: Official Journal of the National Association of Directors of Nursing Administration in Long Term Care (NADONA)
National Association of Directors of Nursing Administration Long Term Care (NADONA)
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