Infeksjonskontroll ved CF ny kunnskap og nye muligheter. Ellen Julie Hunstad, kl.spl.spes. Norsk senter for cystisk fibrose

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1 Infeksjonskontroll ved CF ny kunnskap og nye muligheter Ellen Julie Hunstad, kl.spl.spes. Norsk senter for cystisk fibrose

2 Infection Control Lungtreatment with mucus mobilisation Cystic fibrosis treatment & follow up Medications Food & Nutrion

3 CF population in Norway - improved health & life expectancy 2008

4 Smittevern gir utfordringer.. 1. cystiskfibrose skole godhelse jobb renehender utstyr smittevern holdeformunnen trening renhold bakterier behandling hoste barnehage desinfeksjon antibiotika sosiale aktiviteter felles utstyr felles leker svømmebasseng gymsal sanitæranlegg sykehushygiene enerom gårdsbesøk husdyr hester vaksiner hygienesanger smittsomme sykdommer Infeksjonskontroll ved cystisk fibrose et påført funksjonshinder gjennom livsløpet. Ellen Julie Hunstad, Funktionshinder ur ett folkhälsoperspektiv, NHV`s rapportserie 2012:9

5 CF research from Norway A Norwegian study Typing of Pseudomonas aeruginosa strains in Norwegian cystic fibrosis patients showed evidence for cross-infection between Norwegian CFpatients. Advicory Board for the Norwegian Association for CF made a new recommendation of hygiene precautions for use in hospital and other social events for persons with CF. (Fluge G & al, 1998/2001)

6 Evidence based recommendations for CF Infection Control Infection Control Recommendations for Patients With Cystic Fibrosis: Microbiology, Important Pathogens, and Infection Control Practices to Prevent Patient-to-Patient Transmission: This consensus document presents background data and evidence-based recommendations for practices that are intended to decrease the risk of transmission of respiratory pathogens among CF patients from contaminated respiratory therapy equipment or the contaminated environment and thereby reduce the burden of respiratory illness. (Saiman L & al, CFF 2003)

7 Infection control recommendations for patients with cystic fibrosis L Saiman,J Siegel, CFF Consensus Conference 2003 CF pathogens are transmitted by the droplet and contact routes. Therefore, practices that contain respiratory secretions and prevent transmission of respiratory tract pathogens must be taught to patients and their families as well as to CF healthcare workers.

8 Infection control recommendations for patients with cystic fibrosis L Saiman,J Siegel, CFF Consensus Conference 2003 Infection control practicies must be followed with all CF patients, and cannot be implemented according to individual CF patients because microbiology methods are not 100% sensitive for all detection of CF pathogens. Cleaning devices such as nebulizers, with removal of debris as soon as possible and before desinfection, and complete air drying are the critical steps in both healthcare and home settings.

9 Standards of care for patients with cystic fibrosis: a European consensus 2005 We are convinced that intensive treatments, both prophylactic and as a response to acute events, decrease morbidity and increase survival and quality of life. E Kerem, S Conway, S Elborn, H Heijerman for the concensus commitee

10 Prevalence of chronic infection with Pseudomonas aeruginosa in 890 pancreatic insufficient CF patients in Denmark, Norway and Sweden (2009)

11 Implementation of European standards of care for cystic fibrosis Control and treatment of infection J.S. Elborn, M. Hodson, C. Bertram. Journal of Cystic Fibrosis 8 (2009) Pulmonary exacerbations can damage a patient's lung tissue and, in people with CF, there is a clear correlation between the number of exacerbations per year and patient age. Exacerbations are most common in the adolescent and adult population with nearly 50% of patients, between the ages of 18 and 30 years, experiencing at least one exacerbation per year. This contrasts with those under 10 years of age of whom 75 85% remain exacerbation free. Recurring exacerbations cause further lung damage and are associated with poorer outcomes.

12 Implementation of European standards of care for cystic fibrosis Control and treatment of infection J.S. Elborn, M. Hodson, C. Bertram. Journal of Cystic Fibrosis 8 (2009) Consensus Guidelines recommend that, in order to minimise cross-infection, beds for patients with CF should be contained in single rooms (which have the additional advantage of facilitating inhaled antibiotic therapy), ideally according to a patient's microbiological status including Pseudomonas subtypes. Such segregation is valuable, especially if epidemic strains are involved.

13 Implementation of European standards of care for cystic fibrosis Control and treatment of infection J.S. Elborn, M. Hodson, C. Bertram. Journal of Cystic Fibrosis 8 (2009) The implementation of clear infection control policies is vital for the control of cross-infection in vulnerable CF patients, as every pulmonary infection can cause further lung damage. The European Consensus Guidelines and European consensus report, recommend that regular monitoring should occur with: patients seen at hospital at least every 3rd month, or ideally every month, and that microbiological samples are obtained at every hospital visit.

14 Recommended infection control in health care - Norway Routines for infection control in health care is under continous professional evaluation for contributing to defencible hygiene precations in patient treatment, together with the individual fysical and psychic health for patients. Segregation of patients with isolation is one of the efforts within infection control that can be necessary for reducing risk of cross infection between persons, both sick and healthy. Efforts with single/isolation room, precautions equiptment and social restriction is stignatising for the patient, and should only be used when medical convinsible for treatment and prognosis. (Aavitsland P, Sykepleien 2009)

15 Kontaminering av medisinsk utstyr og kryssmitte er beskrevet.. Håndtering av pasientnært utstyr som respirasjonsutstyr ( Brukt utstyr som er forurenset med kroppsvæsker eller som på annen måte kan være forurenset med smittestoffer, håndteres på en slik måte at det ikke kommer i kontakt med hud eller slimhinner, tøy eller utstyr. Alt utstyr som skal brukes om igjen må være omhyggelig rengjort og desinfisert eller sterilisert før det brukes til andre pasienter. Engangsutstyr skal ikke brukes om igjen, og kastes etter gjeldende rutiner. Ordningen med behandlingshjelpemidler i Norge har ikke formalisert krav til rutiner for smittevern ved gjenbruk og resirkulering av medisinsk teknisk utstyr. Behandlingshjelpemidler for hjemmeboende pasienter foreligger det kryssmitte ved gjenbruk og resirkulering av medisinsk teknisk utstyr? Ellen Julie Hunstad, Diplomoppgave i smittevern, NHV 2011

16 From CF Foundation Annual Report

17 Beneficial Impact of Awareness to CF Infection Control Guidelines on Adherence, Familiarity, and Attitude Barriers survey items Adherence to guideline 1. Educate CF patients to clean and disinfect home nebuliser after use Familiarity with guideline Agreement with guideline 2. Overall content of guideline* 3. CF patients should avoid socialisation during hospitalisation 4. Educate CF patients to perform hand hygiene 5. Educate CF patients to clean and disinfect home nebuliser 6. Clean exam rooms between CF patient use 7. Quarterly cultures of respiratory tract are useful for CF 8. CF patients should avoid socialisation during hospitalisation Self-efficacy (confidence in ability to practice guideline) Outcome expectancy (belief that practicing guideline will improve patient outcome) 9. Collect quarterly cultures of respiratory tract 10. Educate CF patients to clean and disinfect home nebuliser 11. Discourage socialisation between CF patients during hospitalisation 12. Discourage socialisation between CF patients during hospitalisation 13. Clean and disinfect home nebuliser Modified from original table from Barriers to Adherence to Cystic Fibrosis Infection Control Guidelines (Garber et al 2008) * International, national and local guidelines Awareness to Infection Control within Cystic Fibrosis Health Care a Scandinavian study. Ellen Julie Hunstad, Master Thesis of Public Health, Nordic School of Public Health 2013.

18 2013: New cross-infection updating guidelines.. CF Trust: New crossinfection guidelines taking shape Draft guidelines on infection control open to CF centres for consultation. Published on Medical The expert cross-infection group set up by the Cystic Fibrosis Trust in the wake of recent research highlighting new risks from multi-resistant bacteria Mycobacterium abscessus has produced a set of draft guidelines for infection control. CF Foundation Updates Infection Prevention and Control Policy for All Foundation Events and Meetings March 14, 2013 The Foundation took this step based on increasing medical evidence of a greater risk that people with CF could spread destructive germs to others with CF, which may lead to severe or worsening lung disease. The new policy reflects the advice of leading CF medical experts and published medical research. The key elements of the Foundation s policy are: Indoor events: At any Foundation-sponsored indoor event or meeting, including gatherings such as chapter committee meetings, only one person with CF may be present and he or she will be designated in close consultation with event chairs and key event volunteers. Outdoor events: At Foundation-sponsored outdoor events or gatherings, people with CF need to maintain a distance of at least 6 feet from each other. B. cepacia: Under no circumstances shall individuals who have ever had a confirmed positive sputum culture for Burkholderia cepacia (B. cepacia) complex attend any Foundation events, meetings or offices.

19 Infeksjonskontroll ved Norsk senter for CF Mikrobiologisk overvåkning larynxaspirat/ekspektorat Antibiotika Vaksiner Koordinering og administrering av pasientvirksomhet Retningslinjer for basal hygiene i helsesektoren Rutiner for smittevern ved CF som.. Hånd- og hostehygiene Enerom evt isolat Individuell lungefysioterapi Personlig inhalasjonsutstyr evt sterilsiert

20 Smittevern ved CF i sykehus anbefaling fra NSCF november 2009 Smittevern Mikrobiologi Pasienter Pasientrom Personell Undersøkelser Pasienthotell Ordinær/god hygienisk standard - med særskilte krav til personlig hygiene E. coli Haemofilus Influenzae Klebs. species Pseudom.aer. Staphyloc.aureus Streptoc. Pneumonia Stenotroph.malto. Serratia Atypiske mykobakterier Hånd- og hostehygiene Eget/sterilisert inhalasjons-utstyr Nær kontakt med andre CF-pasienter frarådes Enerom Daglig vask inkl alle horisontale flater, vask, bad God ventilasjon Håndhygiene Stellefrakk ved behov Individuell fysioterapi Ingen restriksjoner Ingen restriksjoner Evt overnatting på pasienthotell Kontaktsmitte (dråpe-) - tilpasset ift risikosituasjo ner ved CF Achromobacter xyloxidans Multires. Pseudom.aer Res. Gramneg. stavbakterier Hånd- og hostehygiene Eget/sterilisert inhal.utstyr Ingen fysisk kontakt med andre CF-pasienter Enerom Gult skilt Daglig vask inkl alle horisontale flater, vask, bad. God ventilasjon Håndhygiene Ved nærkontakt bruk stellefrakk + hansker Individuell fysioterapi Evt restriksjoner ved undersøkelser/ lungefunksjonsmålinger Overnatting på pasienthotell kan vurderes Luftsmitte Burkh.cepacia MRSA TBC inkl humane tbcbakterier (åpen tbc) Pandorea apista? Andre? Hånd- og hostehygiene Munnbind utenfor sykerommet Eget/sterilisert inhal.utstyr Ingen fysisk kontakt med andre CF-pasienter Enerom Rosa skilt Luftsmitteisolat Daglig vask inkl alle horisontale flater, vask, bad. Streng håndhygiene Stellefrakk + munnbind + hansker Individuell fysioterapi Isolasjon i sengepost Restriksjoner ved undersøkelser/ lungefunksjonsmålinger

21 Kvalitetsforbedring innen CF infeksjonskontroll

22 Rengjøring av inhalasjonsutstyr ved cystisk fibrose Daglig rengjøring av forstøverbeger med munnstykke eller maske Etter hver bruk - ta delene fra hverandre og.. skyll i varmt vann med litt oppvaskmiddel rist godt for å få ut vann og dråper Daglig x 1 (pga risiko for resmitte av eget utstyr) - koking i.. oppvaskmaskin alene! kjele 4-10 minutter i kokende vann (tidsbruk - se utstyrsveiledning) vannkoker slå kokende vann over utstyret Personlig desinfeksjonsapparat/ dampsterilisator følg veiledning La delene lufttørke på rent og tørt underlag Oppbevares i rent og tørt håndkle på rent og tørt sted

23 Behandlingshjelpemidler anbefaling ved cystisk fibrose Ikke resirkulert utstyr til personer med CF pga risiko for bakteriell smitte ved resirkulering av utstyr Inntil 3 inhalasjonsapparater (2 strøm + 1 batteri) Skifte av forbruksmateriell minst x 2 pr år for hvert apparat (forstøverbegere, slanger, filter) - minimum Munnstykke/maske - evt etter behov (min x 2 pr år) Årlig kontroll av behandlingshjelpemidler (medisinsk-teknisk utstyr) Inhalasjonsapparater, sondepumper, oksygenutstyr Teknisk vurdering og kontroll Skifte av innvendige slanger + tekniske deler ved behov Innvendig rengjøring og desinfeksjonsgassing Ta kontakt med BHM for avtale

24 En velbrukt CR 60..

25 Sterinis desinfeksjonsrobot for behandlingshjelpemidler og sykehus Anbefales for desinfeksjon x 1 pr år av: Inhalasjonsapparater Sondepumper Insulinpumper Oksygen-apparater Dreper effektivt bakterier, virus og muggsopp - med unntak av mykobakterier. Roboten sprer ut tørr tåke av hydrogenperoksyd i et lukket rom. Mikrobene trekker til seg tåken, kapsles inn og drepes.

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