Preventing and Controlling The Transmission of Infectious Agents

What percentage of Creutzfeldt-Jakob disease (CJD) cases are sporadic (vs. familial)? a. 65 percent b. 85 percent c. 15 percent d. 1 percent

85 percent Rationale: CJD occurs naturally in either of two forms: the sporadic type (occurring at a rate of 1 case per 1 million population) and the familial type due to a genetic mutation that can be passed from generation to generation and has been documented in geographical clusters in various parts of the world. The percentage of sporadic CJD is 85 percent. Sporadic CJD has no gender restrictions and occurs at a mean onset of 50 to 70 years of age. Reference: APIC Text, 4th edition, Chapter 73 - Creutzfeldt-Jakob Disease and Other Prion Diseases

The IP has been asked to join the Antimicrobial Stewardship Team at his facility. The IP reviews current recommendations and understands that effective strategies to curb antimicrobial resistance include all of the following except: a. Formulary restriction b. Administer antibiotics with overlapping activity c. Automatic stop orders d. Antimicrobial cycling

Administer antibiotics with overlapping activity Rationale: Antimicrobial stewardship refers to coordinated interventions designed to improve and measure the appropriate use of antimicrobials by promoting the selection of the optimal antimicrobial drug regimen, dose, duration of therapy, and route of administration. Antimicrobial stewardship is the best investment for preventing the proliferation of multidrug-resistant pathogens and the adverse events associated with the drugs used to treat such pathogens. Recommended strategies for antimicrobial stewardship include formulary restriction, automatic stop orders, and antimicrobial cycling. Reference: APIC Text, 4th edition, Chapter 26 - Antimicrobials and Resistance

Which type of isolation always requires a private room? a. Contact Precautions b. Standard Precautions c. Airborne Precautions d. Droplet Precautions

Airborne Precautions Rationale: According to the CDC Isolation Guidelines, private rooms are not required for Contact and Droplet Precautions (though they are preferred). Patients on Contact or Droplet isolation with the same disease may share a room if necessary. Patients on Airborne Isolation require a private room. Reference: APIC Text, 4th edition, Chapter 29 - Isolation Precautions (Transmission-based Precautions)

An urban community is experiencing an outbreak of Bordetella pertussis. Several employees have contacted the IP at their healthcare facility for information on the tetanus, diphtheria, and pertussis (Tdap) vaccine. They question the need for the vaccine because they received it as a child. The IP should inform them that the Advisory Committee for Immunization Practices (ACIP) recommends that: a. All adults aged 19 and older should receive at least one dose of Tdap b. If the employee is pregnant, she should not receive the vaccine c. All individuals must receive the vaccine every 10 years d. Individuals who have had the disease do not need to receive the vaccine

All adults aged 19 and older should receive at least one dose of Tdap Rationale: Pertussis (whooping cough) is a highly communicable, acute, infectious respiratory disease caused by Bordetella pertussis. ACIP recommends a single Tdap dose for persons aged 11 to 18 years who have completed the recommended childhood diphtheria and tetanus toxoids and pertussis/diphtheria and tetanus toxoids and acellular pertussis (DTP/DTaP) vaccination series and for adults aged 19 to 64 years. Reference: Centers for Disease Control and Prevention. Updated Recommendations for Use of Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis (Tdap) Vaccine from the Advisory Committee on Immunization Practices, 2010. MMWR 2011 Jan 14;60(01):13-15.

An autopsy is ordered on a patient who was diagnosed with tuberculosis (TB). Which of the following statements is correct regarding postmortem care of a deceased TB patient? a. Autopsy rooms should be at positive pressure with respect to adjacent areas, and room air must be exhausted directly outside b. An oscillating autopsy saw should be used to reduce the infectious aerosols c. An approved mask is necessary for respiratory protection d. Standard Precautions are sufficient because Mycobacterium tuberculosis needs a living host to survive

An approved mask is necessary for respiratory protection Rationale: OSHA classifies performance of an autopsy on a known or suspected case of TB to be a high-hazard procedure requiring personnel to use approved respiratory protection. In areas where TB is prevalent and the health history is unknown, respiratory protection is prudent, especially for medical examiner's cases. Reference: APIC Text, 4th edition, Chapter 65 - Postmortem Care

Which of the following does not meet the requirements for an airborne isolation room? a. Negative airflow isolation room (negative air pressure relative to the corridor) b. At least 15 to 20 air exchanges per hour c. Direct exhaust to the outside d. Daily monitoring of the air pressure with visual indicators

At least 15 to 20 air exchanges per hour Rationale: Airborne Precautions are used to prevent transmission of infectious organisms that remain suspended in the air and travel great distances. These diseases include measles, smallpox, chickenpox, pulmonary tuberculosis, avian influenza, and possibly SARS-associated coronavirus. In acute care and long¬term care settings, patients should be placed in an airborne infection isolation room (AIIR) with negative air pressure relative to the corridor and at least 6 to 12 air exchanges with direct exhaust of air to the outside. Air pressure should be monitored daily with visual indicators (e.g., smoke tubes, flutter strips). The door should be kept shut. Reference: APIC Text, 4th edition, Chapter 29 - Isolation Precautions (Transmission-based Precautions)

Most healthcare-associated pathogens are transmitted from patient to patient via: a. Improper isolation practices b. Inadequate sterilization of medical instruments c. Hands of healthcare personnel d. Ineffective disinfection of medical devices

Hands of healthcare personnel Rationale: According to literature, most healthcare-associated pathogens are transmitted from patient to patient via the hands of healthcare personnel. Hand hygiene, therefore, is the simplest and most effective, proven method to reduce the incidence of HAls. Reference: APIC Text, 4th edition, Chapter 8 - Legal Issues

According to the Centers for Disease Control and Prevention (CDC), central venous catheters (CVCs) should be replaced: a. Every 72 to 96 hours b. Every 7 days c. After 1 month d. If malfunctioning

If malfunctioning Rationale: According to the CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections, CVCs, PICCs, hemodialysis catheters, or pulmonary artery catheters should not be routinely removed to prevent catheter-related infections. A guidewire exchange should be used to replace a malfunctioning nontunneled catheter if no evidence of infection is present. Reference: APIC Text, 4th edition, Chapter 34 - Intravascular Device Infections

During an influenza outbreak in an acute care setting, all of the following measures should be implemented except: a. Perform rapid influenza virus testing of patients and personnel with recent onset of symptoms suggestive of influenza b. Implement Airborne Precautions for all patients with suspected or confirmed influenza c. Restrict staff movement from areas of the facility having outbreaks d. Restrict or limit elective medical and surgical admissions

Implement Airborne Precautions for all patients with suspected or confirmed influenza Rationale: During an influenza outbreak in an acute care setting, the following measures should be taken to protect patients and staff and to reduce the risk of healthcare-associated influenza transmission: • Perform rapid influenza virus testing of patients and personnel with recent onset of symptoms suggestive of influenza. • Implement Droplet Precautions for all patients with suspected or confirmed influenza. • Separate suspected or confirmed influenza patients from asymptomatic patients. • Restrict staff movement from areas of the facility having outbreaks. • Immunize unvaccinated patients and healthcare personnel with current recommended, available influenza vaccine. • Administer influenza antiviral chernoprophylaxis and treatment to patients and healthcare personnel according to current recommendations. • Consider antiviral chemoprophylaxis for all healthcare personnel, regardless of their vaccination status, if the health department determines the outbreak is caused by a variant of influenza virus that is a suboptimal match with the vaccine. • Limit or stop elective medical and surgical admissions. • Restrict cardiovascular and pulmonary surgery to emergency cases during influenza outbreaks, especially those characterized by high attack rates and severe illness, in the community or acute care facility. Reference: APIC Text, 4th edition, Chapter 82 - Influenza

An outbreak of aspergillosis is suspected after several oncology patients are identified with positive cultures. The IP suspects a heating, ventilation, and air conditioning (HVAC) malfunction and begins an outbreak investigation. The P has been asked to make recommendations for environmental cultures. All of the following needs to be considered except: a. Identifying the purpose of culturing and appropriate methods beforehand b. Meeting with the facility legal staff to discuss notification of the patients c. Anticipating decisions and planned actions to results of culturing before undertaking the process d. Determining whether there are existing standards to interpret results

Meeting with the facility legal staff to discuss notification of the patients Rationale: When an outbreak is identified or suspected, an environmental source may be present, and confirmatory testing is appropriate. A critical review of the indications for airborne particulate monitoring or cultures must be done in light of basic principles of outbreak investigation (e.g., establishing that an outbreak exists). One may also consider the following guidance: • Purpose of culturing and appropriate methods should be identified beforehand. • Decisions and planned actions regarding results of culturing should be anticipated before undertaking the process. • Determination should be made whether there are existing standards to interpret results. Reference: APIC Text, 4th edition, Chapter 114 - Heating, Ventilation, and Air Conditioning

The CDC recommendations for decreasing CLABSI include all of the following except: a. Educational programs b. Routine replacement of catheters c. The use of chlorhexidine for skin antisepsis d. The use of maximal sterile barrier precautions

Routine replacement of catheters Rationale: The CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections do not recommend routinely replacing CVCs, PICCs, hernodialysis catheters, or pulmonary artery catheters to prevent catheter-related infections. Reference: APIC Text, 4th edition, Chapter 34 - lntravascular Device Infections

The policy for therapy animals in healthcare facilities should include all of the following except: a. Hand hygiene must be performed after contact with the animal b. Animal must be bathed within 24 hours prior to visiting the healthcare facility c. Animals must be healthy and current with immunizations d. Small animals are never allowed to sit on a patient's bed

Small animals are never allowed to sit on a patient's bed Rationale: Healthcare facilities should develop and implement infection prevention guidelines and develop policies to minimize the potential risks associated with having animals in healthcare facilities. These should require that animals be of good temperament, well-groomed, and healthy and that that their handlers be educated on infection prevention practices, including hand hygiene. The following infection prevention and safety guidelines should be in place: • The healthcare facility develops policies and guidelines for the safety of the patients and animals involved in visitation, animal-assisted activities, and animal-assisted therapy. The healthcare facility should designate a person or persons to implement the policies, coordinate animal-human interactions, and act as a liaison to the animal handlers visiting the facility. • Participating animals must have a temperament test (behavioral assessment) by an experienced person or recognized group. • Animals are required to be bathed within 24 hours before the visit. • Animals may wear a shirt, vest, or other protective clothing to control allergies. Wiping the animal with a baby or pet wipe will help control dandruff. • Animals must have clean ears. • Animals must have nails that are short with no rough edges. Animals must be trained not to scratch the patient. For additional protection, animals may wear protective foot coverings. • Animals must be healthy and current with immunizations, including rabies vaccination and others required in the state in which the healthcare facility is located. An annual physical examination by a licensed veterinarian should include dental and dermatological evaluation. Animals should be free of communicable diseases and parasites and be on a flea control program. • Animals must be free of any skin condition or wounds. • Handlers must ensure th6t animals do not lick or come in contact with a patient's open wound or devices. • If an animal is allowed on a patient's bed, a barrier such as a disposable cloth, towel, or sheet can be placed between the animal's coat and the patient's linen. The barrier is removed and discarded when the animal leaves. • Animals are kept on a short leash or in a carrier or basket. The use of retractable leashes is discouraged. • The animal's handler/volunteer must be healthy and free of communicable diseases. The facility is strongly encouraged to consider a recommendation to handlers that they receive annual influenza shots and may be able to offer the vaccine to handlers for free as part of the annual flu vaccination program. Reference: APIC Text, 4th edition, Chapter 122 - Animals Visiting Healthcare Facilities

An RN is caring for a patient who presented to the Emergency Department with symptoms consistent with influenza. When caring for this patient, she should use which of the following types of precautions? a. Standard Precautions b. Standard and Droplet Precautions c. Airborne Precautions d. Droplet Precautions if influenza is confirmed

Standard and Droplet Precautions Rationale: Influenza viruses are spread from person to person primarily through large-particle respiratory droplet transmission. Transmission via large- particle droplets requires close contact between source and recipient persons, because droplets do not remain suspended in the air and generally travel only a short distance (1 meter or less) through the air. Droplet Precautions are intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. Standard precautions apply to all patients, regardless of suspected or confirmed infection Status. Reference: APIC Text, 4th edition, Chapter 82 - influenza

Which of the following statements is true regarding CVCs? a. Anticoagulant therapy can reduce the risk of catheter-related infection b. Positioning at the insertion site minimizes catheter tip malposition c. The CVC should be sutured in place d. Stopcocks can increase the contamination rate

Stopcocks can increase the contamination rate Rationale: According to the CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections, a CVC with the minimum number of ports or lumens essential for the management of the patient should be used. Stopcocks used for injection of medications, administration of IV infusions, and collection of blood samples represent a potential portal of entry for microorganisms into vascular access catheters and IV fluids. Stopcocks should be capped when not being used. In general, closed catheter access systems are associated with fewer catheter-related infections than open systems and should be used preferentially. Reference: APIC Text, 4th edition, Chapter 34 - Intravascular Device Infections

While making rounds in one of the Intensive Care Units, the IP observes a patient who has just been intubated and is on a ventilator. He notes that the patient is in a supine position. Which of the following positions should he recommend to the nurse in order to be compliant with a pneumonia prevention bundle? a. The patient should be turned to his side to facilitate drainage of secretions b. The patient should be placed in reverse Trendelenburg position c. The patient's head of the bed should be elevated to an angle of 30 to 45 degrees d. The patient should sit upright at a 60 to 75 degree angle

The patient's head of the bed should be elevated to an angle of 30 to 45 degrees Rationale: There are five components of care to prevent VAP: 1 Elevation of the head of the bed 2. Daily sedative interruption and assessment of readiness to extubate 3. Peptic ulcer disease prophylaxis 4. Deep vein thrombosis prophylaxis 5. Daily oral care with chlorhexidine Reference: APIC Text, 4th edition, Chapter 36 - Pneumonia

Which federal agencies in the United States have published regulations pertaining to infection and medical or regulated waste? 1) U.S. Environmental Protection Agency (EPA) 2) U.S. Occupational Safety and Health Administration (OSHA) 3) U.S. Food and Drug Administration (FDA) 4) U.S. Department of Transportation (DOT) a. 1, 2, 3 b. 2, 3, 4 c. 1, 2, 4 d. 1, 3, 4

1, 2, 4 Rationale: On the federal level in the United States, several agencies have published regulations pertaining to "infectious," "medical," or "regulated" waste. The U.S. EPA, OSHA, and DOT have such regulations. In addition, both the CDC and EPA have issued guidance documents pertaining to medical waste management. At the request of the U.S. Congress, the Agency for Toxic Substances and Disease Registry prepared and published a comprehensive review.of the public health implications of medical waste. Reference: APIC Text, 4th edition, Chapter 113 - Waste Management

Exposure to contaminated healthcare waste does not necessarily result in infection. The following factors must be present for contaminated waste to be capable of causing infection: 1) Dose and host susceptibility 2) Portal of entry 3) Portal of exit 4) Presence and virulence of a pathogen a. 1, 3, 4 b. 1, 2, 4 c. 2, 3, 4 d. 1, 2, 3

1, 2, 4 Rationale: Pathogenic organisms are found in many different day-to-day settings. Household garbage, bed linens, soiled diapers, and unwashed hands are all examples of environments in which pathogens can be found routinely. A number of studies have shown that though hospital wastes can have a greater variety of organisms than residential wastes, those from households are more heavily contaminated. For waste to be capable of causing infection, the following specific factors are necessary: (1) dose, (2) host susceptibility, (3) presence of a pathogen, (4) virulence of a pathogen, and (5) portal of entry. All five of these factors must be present for infection to occur from waste. Reference: APIC Text, Chapter 113 - Waste Management

Which of the following statements is true regarding the storage of sterilized items in the Sterile Processing Department? 1) Sterilized items should be stored on a shelf with a solid bottom 2) Sterilized items should be stored in high traffic areas for easy access 3) Sterilized items should be stored in a room with positive air pressure 4) Sterilized items should be stored 8 to 10 inches from the floor a. 1, 2, 3 b. 1, 3, 4 c. 2, 3, 4 d. 1, 2, 4

1, 3, 4 Rationale: Physical storage restrictions are recommended to support an environment that is conducive to maintaining the sterility of reprocessed items. Sterilized items should be stored as follows: • Eighteen inches from the ceiling if there is a sprinkler head or according to the fire code • Eight to 10 inches from the floor • At least 2 inches from an outside wall • Away from sprinklers and air vents • In areas of limited traffic • Clean workroom or clean holding area(s): Airflow must be positive pressure with respect to surrounding areas with a minimum of four air exchanges per hour. In an area with controlled temperature and humidity (18°C to 22°C [65°F to 72°F], relative humidity less than 35 to 75 percent, and at least 4 [preferably 10] air exchanges per hour). • Soiled workroom or soiled holding area(s): Airflow must be negative pressure with respect to surrounding areas with a minimum of 10 air exchanges per hour. • The first item in is the first item out (first in first out [FIFO]). Items should be rotated. Place newer items in the back part of the area where they are stored. • Open-rack storage should have a solid bottom to prevent soiling or contamination from the floor • Consideration should be given to storage that will minimize the collection of dust on surfaces • Sterilized items should be arranged in a manner that prevents packages from being crushed, bent, compressed, or punctured. Items should not be stored under sinks or under exposed water or sewer pipes. Windowsills should be avoided. Closed or covered cabinets are preferred. Open shelving may be used if the area has limited access, has monitored ventilation, and is frequently cleaned and disinfected. Reference: AP1C Text, 4th edition, Chapter 106 - Sterile Processing

Numerous outbreaks of infections have been attributed to unsafe injection practices. The IP designs an educational program to review safe injection practices with all nursing staff. These practices include: 1) Use single-dose vials whenever possible and avoid using multidose vials 2) Discard saline bags used for intravenous (IV) flushes for multiple patients after 1 hour 3) Enter medication vials with a new needle and syringe, even on the same patient 4) Use needles and syringes for only one patient a. 1, 2, 3 b. 1, 3, 4 c. 1, 2, 4 d. 2, 3, 4

1, 3, 4 Rationale: Since 1999, more than 125,000 patients in the United States have been notified of potential exposure to Hepatitis B virus, Hepatitis C virus (HCV), and HIV due to unsafe injection practices. Many of these incidents involved healthcare providers reusing syringes, resulting in contamination of medication vials or containers, which were used then on subsequent patients. Injection safety and other basic infection control practices are central to patient safety. Safe injection practices include: • Never administer medications from the same syringe to more than one patient, even if the needle is changed • Do not enter a vial with a used syringe or needle • Medications packaged as single-use vials must never be used for more than one patient • Medications packaged as multiuse vials should be assigned to a single patient whenever possible • Bags or bottles of IV solution must not be used as a common source of supply for more than one patient • Absolute adherence to proper infection control practices must be maintained during the preparation and administration of injected medications References: APIC Text, 4th edition, Chapter 21 - Risk Factors Facilitating Transmission of Infectious Agents; Centers for Disease Control and Prevention (CDC). The One and Only Campaign. CDC website. Available at: http://www. cdc,gov/injectionsafety/lanOnly.html

An IP has been asked to provide infection prevention consultation to a long-term care facility (LTCF). As a part of this consultation, she checks to make sure which of the following program components are in place: 1) Decolonizing residents with MRSA 2) Establishing an antimicrobial stewardship program 3) Implementing an annual influenza vaccination program 4) Collecting environmental cultures of high-touch areas a. 1, 2 b. 2, 3 c. 3, 4 d. 1, 4

2,3 Rationale: Antibiotic resistance continues to pose a significant problem for residents in LTCFs because of the overuse and misuse of antibiotics. Antimicrobial stewardship refers to coordinated interventions designed to improve and measure the appropriate use of antimicrobials by promoting the selection of the optimal antimicrobial drug regimen, dose, duration of therapy, and route of administration. The Infectious Diseases Society of America and the.Society for Healthcare Epidemiology of America support broad implementation of antimicrobial stewardship programs across all healthcare settings including LTCFs. In addition, it is recommended that influenza vaccination be provided to all residents of LTCFs. Influenza outbreaks in LTCFs may have severe and even deadly consequences for residents. Because influenza is easily transmitted, it is important that influenza vaccination is offered to all residents to provide both individual protection and "herd immunity" (i.e., group protection) in the LTCF. Research has shown the effectiveness of influenza immunization programs among the geriatric population and long-term care resident. References: APIC Text, 4th edition, Chapter 61 - Long-term Care; Dellit TH, Owens RC, McGowan JE, et al. infectious Diseases Society of America and the Society for Healthcare Epidemiology of America Guidelines for Developing an Institutional Program to Enhance Antimicrobial Stewardship. Clin Infect Dis 2007;44 (2): 159-177.

The U.S. Phamacopoeia (USP) recommends that multidose vials be disposed of: a. 14 days after opening b. 30 days after opening c. 28 days after opening d. When all the medication has been used

28 days after opening Rationale: A multidose vial is a vial of liquid medication intended for parenteral administration (injection or infusion) that contains more than one dose of medication. Multidose vials are labeled as such by the manufacturer and typically contain an antimicrobial preservative to help prevent the growth of bacteria. The preservative has no effect on viruses and does not protect against contamination when healthcare personnel fail to follow safe injection practices. USP Standard <797> requires that a multidose vial be discarded within 28 days after its first opening in accordance with USP Chapter <51> unless specified by the manufacturer. The CDC recommends refrigerating the vials after opening if recommended by the manufacturer, cleaning the rubber diaphragm of the vial with alcohol before inserting a device into the vial, using a sterile device each time a vial is accessed, and avoiding touch contamination of the device before penetrating the rubber diaphragm. The multidose vial should be discarded when empty, when suspected or visible contamination occurs, or when the manufacturer's stated expiration date is reached. Medications packaged as multidose should be assigned to a single patient whenever possible. Reference: APIC Text, 4th edition, Chapter 110 - Pharmacy Services

Of the following methods of disinfection and sterilization, which will kill all organisms, including all bacterial spores? 1) Pasteurization 2) Ortho-phthalaldehyde 3) Steam sterilization 4) Ethylene oxide a. 1, 2 b. 2, 3 c. 1, 3 d. 3, 4

3, 4 Rationale: Both steam sterilization and ethylene oxide gas sterilization will kill bacterial spores and all other microorganisms. Steam sterilization can only be used for items that are tolerant of high temperatures, such as metal surgical tools. Ethylene oxide gas sterilization is a low-heat method for items that are not heat tolerant. Items that are sterilized by ethylene oxide must be allowed time for aeration before use. Reference: APIC Text, 4th edition, Chapter 31 - Cleaning, Disinfection, and Sterilization

Which of the following situations present the greatest risk for the transmission of pathogens via healthcare personnel hands? 1) Unit secretary with artificial nails 2) Environmental services worker with unchipped nail polish 3) Nurse practitioner with artificial nails 4) Registered nurse (RN) with chipped nail polish a. 1,2 b. 2,3 c. 3, 4 d. 1, 4

3,4 Rationale: Freshly applied nail polish does not increase the number of bacteria recovered from periungual skin, but chipped nail polish may support the growth of larger numbers of organisms on fingernails. However, healthcare personnel who wear artificial nails are more likely to harbor Gram-negative pathogens on their fingertips than are those who have natural nails, both before and after hand washing. Reference: Boyce JM, Pittet D. Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR 2002 October, 51(RR-16):1-45. Available at: http://www.cdc.gov/ mmwr/PDF/rr/rr5116.pdf.

Which of the following is recommended for use when inserting a central venous catheter or a peripherally inserted catheter? a. A cap b. A clean gown c. Nonsterile gloves d. Small drapes

A cap Rationale: According to the CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections, maximal sterile barrier precautions must be used for the insertion of CVCs, PICCs, or guidewire exchanges. This includes the use of a cap, mask, sterile gown, sterile gloves, and a sterile full-body drape for the insertion. Reference: APIC Text, 4th edition, Chapter 34 - Intravascular Device Infections

While the IP performs environmental rounds in the Pharmacy, she observes a pharmacy technician using poor technique while working under the laminar airflow hood. She reviews the Pharmacy's policy for the frequency of training on aseptic technique for employees preparing sterile solutions. Which of the following is the best recommended frequency of infection prevention and control training for unlicensed employees who prepare sterile solutions? a. Monthly until the employee can demonstrate proficiency by return demonstration b. Every 6 months for 1 year after the date of hire c. Annually on employee's anniversary date of hire with other training programs d. Annually and whenever unacceptable technique is observed

Annually and whenever unacceptable techniques are observed Rationale: Quality problems associated with compounded sterile and nonsterile pharmacy preparations have resulted in recalls, patient injury, and death. The American Society of Health System Pharmacists requires that all personnel be properly trained by the following means: • Prior to commencing any compounding, perform thorough didactic instruction in the theory and practice of sterile preparations, with evaluation of technique annually (for low- and medium-risk level) and semiannually (for high-risk level) • Compounder evaluations should include a formal written exam and practical evaluation of aseptic technique using growth media (media fills) Reference: APIC Text, 4th edition, Chapter 110 - Pharmacy Services

The CDC and WHO guidelines for hand hygiene recommend the use of an alcohol-based hand rub in all of the following situations except: a. After direct patient contact b. Before donning sterile glove c. When hands are visibly soiled d. When moving from a contaminated body site to a clean body site during patient care

C. When hands are visibly soiled Rationale: Hand hygiene is a critical component of patient and employee safety. Use of alcohol-based hand rubs has increased adherence of healthcare personnel to recommended hand hygiene policies and have been associated with reduced HAI, rate. However, when hands are heavily soiled or greasy, hand sanitizers may not work well Hand washing with soap and water is recommended in such circumstances. References: APIC Text, 4th edition, Chapter 27 - Hand Hygiene; Boyce JM, Pittet D. Guideline for hand hygiene in health-care settings. Morbid Mortal Weekly Rev. 2002 Oct25;51(RR1):1-44; World Health Organization (WHO). WHO Guidelines on Hand Hygiene in Health Care. WHO website. 2009. Available at: http://whdlibdocwho.int/publications/2009/9789241597906_eng.pdf?ua=1

Which of the following is not part of the bundle practices to reduce VAP? a. Keeping the head of the bed raised to 30 to 45 degrees elevation unless medically contraindicated b. Performing regular oral care on a ventilated patient c. Taking sedation "vacations" to assess patients' ability to breathe on their own d. Changing ventilator circuits every 48 hours

Changing ventilator circuits every 48 hours Rationale: The following best practices, often included in a ventilator bundle, can help prevent VAP: • Keep the head of the patient's bed raised between 30 and 45 degrees unless other medical conditions do not allow this to occur. • Check the patient's ability to breathe on his or her own every day so that the patient can be taken off of the ventilator as soon as possible. • Clean the patient's hands with soap and water or an alcohol-based hand rub before and after touching the patient or the ventilator. • Clean the inside of the patient's mouth on a regular basis. • Clean or replace equipment between uses on different patients. Reference: APIC Text, 4th edition, Chapter 36 - Pneumonia

A patient is admitted with pruritic lesions on the hands, webs of fingers, wrists, extensor surfaces of elbows and knees, and the outer surfaces of the feet, armpits, buttocks, and waist. What type of isolation does this person require? a. Contact b. Droplet c. Airborne d. No isolation required

Contact Rationale: Skin infestation by the mite Sarcoptes scabiei var. hominis is commonly known as scabies. Mites are transmitted through direct contact with infested persons; less frequently, transmission may occur through contact with clothing or bedding (fomites). Spread of the mite to a different part of the body can occur by manual transfer or scratching. Because of the high risk of transmission, the diagnosis of scabies should be considered in any patient with a pruritic cutaneous eruption, especially those involving the hands, wrist, and elbows. Patients in a hospital or other healthcare facility should be placed in Contact Precautions until 24 hours after treatment. Reference: APIC Text, 4th edition, Chapter 99 - Parasites

Respiratory hygiene/cough etiquette includes all but the following: a. Covering the mouth and nose with the hands when coughing and sneezing b. Offering a surgical mask to a coughing patient c. Discarding used masks and tissues appropriately and performing hand hygiene d. Posting signs in public areas in languages appropriate to the population served and educating healthcare staff, patients, and visitors

Covering the mouth and nose with the hands when coughing and sneezing Rationale: According to the CDC, respiratory hygiene/cough etiquette strategies are used to prevent the transmission of all respiratory infections in healthcare settings. Respiratory hygiene and cough etiquette include covering the mouth and nose with a tissue during coughing and sneezing or offering a surgical mask to the coughing patient, discarding the mask or tissue appropriately and performing hand hygiene, posting signs in public areas in languages appropriate to the population served, and educating healthcare staff, patients, and visitors. Reference: APIC Text, 4th edition, Chapter 29 - Isolation Precautions (Transmission-based Precautions)

What is not considered a risk factor for young girls to develop a urinary tract infection? a. Bubble baths and prolonged soaking in the bathtub b. Direction of wiping with toilet paper (from back to front) c. Excessive holding of urine d. Delayed bladder emptying

Direction of wiping with toilet paper (from back to front) Rationale: Approximately 2.2 percent of girls under the age of 2 develop a urinary tract infection (UTI). Risk factors for young girls include: • History of maternal UTI • Family history of vesicoureteral reflux • History of dysfunctional voiding patterns • Constipation Although often reported as a cause, direction of wiping with toilet paper is not a risk factor. Identified risk factors include bubble baths and prolonged soaking in the bathtub, excessive holding of urine, and delayed bladder emptying. Reference: APIC Text, 4th edition, Chapter 33 - Urinary Tract Infection

A patient with bacterial meningitis due to Neisseria meningitidis requires what type of Transmission-based Precautions? a. Contact Precautions b. Standard Precautions c. Droplet Precautions d. Airborne Precautions

Droplet Precautions Rationale: N. meningitidis is an aerobic, Gram-negative diplococcus that colonizes the nasopharynx of many healthy individuals. Microbial and host factors combine to allow this organism to invade the bloodstream and enter the central nervous system, causing severe sepsis and meningitis. Hypervirulent strains may be transmitted from person to person through respiratory secretions, causing outbreaks of meningococcal disease. Rapid identification of the pathogen, institution of Droplet Precautions based on suspicion of meningococcal disease, initiation of appropriate antibiotic therapy, and administration of chemoprophylaxis of healthcare personnel who were in direct contact with the patient's nasopharyngeal secretions are the most important interventions. Reference: APIC Text, 4th edition, Chapter 29 - Isolation Precautions (Transmission-based Precautions)

Coughing, sneezing, and talking are best associated with which form of disease transmission? a. Airborne transmission b. Direct contact transmission c. Droplet transmission d. Indirect contact transmission

Droplet transmission Rationale: Respiratory droplets carrying infectious pathogens transmit infection when they travel directly from the respiratory tract of the infectious individual to susceptible mucosal surfaces of the recipient. Transmission occurs when large droplets (greater than 5 Km) containing the infectious agent are propelled a short distance through the air (e.g.; by coughing, sneezing, or talking) and come into direct contact with conjunctivae or mucous membranes. When droplets land or infectious secretions are deposited on surfaces close to the patient, pathogens can be acquired indirectly by healthcare personnel. Reference: APIC Text, 4th edition, Chapter 21 - Risk Factors Facilitating Transmission of Infectious Agents

The IP should recommend all of the following prevention measures for a pregnant influenza-infected patient during delivery except: a. During labor and delivery, the patient should wear a mask b. The patient should be placed on Droplet Precautions c. After the infant is born, the mother should wear a surgical mask and then practice hand hygiene before handling the baby d. All persons who come within 3 feet of the mother should wear a surgical mask and practice hand hygiene before and after contact with the mother

During labor and delivery, the patient should wear a mask Rationale: Pregnant women and infants are at increased risk of hospitalization from influenza complications. Pregnant women with influenza in the Labor and Delivery suite should be placed on Droplet Precautions; she does not need to wear a mask during the time of delivery. After the infant is born, the mother should put on a surgical mask and then practice hand hygiene before handling the baby. All persons who come within 3 feet of the mother should wear a surgical mask and practice hand hygiene before and after contact with the mother. All persont in the delivery room should practice hand hygiene before and after handling the baby. Reference: APIC Text, 4th edition, Chapter 82 - Influenza

Antimicrobial stewardship promotes the judicious use of antimicrobials to: a. Increase antimicrobial selective pressure b. Ensure that the right therapy is given to the right patient with the right dose and duration c. Support the development of new antimicrobials d. Contain healthcare costs

Ensure that the right therapy is given to the right patient with the right dose and duration Rationale: Antimicrobial stewardship refers to coordinated interventions designed to improve and measure the appropriate use of antimicrobials by promoting the selection of the optimal antimicrobial drug regimen, dose, duration of therapy, and route of administration. Antimicrobial stewards seek to achieve optimal clinical outcomes related to antimicrobial use, minimize toxicity and other adverse events, reduce the costs of health care for infections, and limit the selection for antimicrobial-resistant strains. Reference: APIC Text, 4th edition, Chapter 26 - Antimicrobials and Resistance; Dellit TH, Owens RC, McGowan JE, et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America Guidelines for Developing an Institutional Program to Enhance Antimicrobial Stewardship. Clin Infect Dis (2007) 44 (2): 159-177.

The epidemiological triangle includes a model of dynamic interaction, where a change in any component alters the existing equilibrium. This model is particularly useful in the study of infectious disease. How can IPs use the epidemiological triangle during outbreak investigations? a. Examination of host factors such as increasing antimicrobial resistance as a result of antibiotic pressure b. Examination of host factors such as changes in immunity or diagnostic/therapeutic procedures within populations served c. Consideration of agent factors such as improving influenza vaccination rates for healthcare workers d. Consideration of agent factors such as a change in cleaning agents used in the hospital environment

Examination of host factors such as changes in immunity, or diagnostic/therapeutic procedures within populations served Rationale: The epidemiological triangle consists of three elements: host, agent, and environment. The host is the human, the environment consists of all external factors associated with the host, and the agent may be a bacteria, virus, fungi, etc. Within the model presented, increasing antimicrobial resistance represents a change in the agent (or pathogen), not a change in the host. Improving healthcare personnel influenza vaccination rates would be an environmental factor change for patients by decreasing their exposure to flu. It is also a host factor change for healthcare personnel because vaccination improved their immunity. A change in cleaning agents represents environmental factors. Host factors such as changes in immunity (e.g., increased numbers of immunocompromised patients) or changes in diagnostic/therapeutic procedures (such as new surgical procedures) would be significant findings for outbreak investigations. The IP can use the epidemiological triangle to analyze and communicate how these changes increased the risk of HAls. Reference: APIC Text, 4th edition, Chapter 10 - General

All of the following maternal infections would require withholding breast milk from the newborn except: a. Breast abscess b. Human immunodeficiency virus (HIV) c. Untreated, active TB d. Hepatitis C

Hepatitis C Rationale: The only infections in which breast milk must be withheld from the newborn are: (1) presence of a breast abscess, (2) herpes simplex virus lesion on breast, and (3) infection with HIV, West Nile virus, or human T-cell lyrnphotropic virus type I or II. If mastitis is present, breast-feeding can continue. If a breast abscess is present, the mother should pump the breast milk and discard it (until 24 to 48 hours after surgical drainage and appropriate antimicrobial therapy). Women with open, active, untreated pulmonary TB cannot breast-feed because they are to have no direct contact with the newborn. However, breast milk can be pumped and given to the newborn, provided that the treatment the woman is receiving is not a contraindication for breast-feeding. Currently, maternal HCV is not considered a contraindication for breast-feeding. The decision to breast-feed in the presence of maternal HCV must be an informed decision made by the woman in consultation with her healthcare provider. Reference: APIC Text, 4th edition, Chapter 43 - Perinatal Care

Hydrogen peroxide vapor (HPV) has been shown to be effective for decontamination of patient rooms and is known to kill spores and other microbes. Despite its benefits, there are some drawbacks to using HPV. Which of.the following could be a major drawback to using HPV to clean patient rooms? a. It is effective in decontaminating surfaces but not equipment b. It leaves a residue that, over time, can damage equipment in the room c. It lengthens room turnover because it takes a prolonged period of time to complete room treatment d. It is most effective for areas closer to the unit and less effective around the edges of the room

It lengthens room turnover because it takes a prolonged period of time to complete room treatment Rationale: The use of HPV has been shown to decrease the incidence of C. difficile infection, and it is effective on surfaces and equipment throughout the room. Drawbacks of this method are that it cannot be utilized while the patient is in the room and that the process lasts a prolonged period of time. Because of these issues, it can be challenging to use for daily cleaning, and it may delay room turnover compared to traditional terminal cleaning methods. Reference: APIC Text, 4th edition, Chapter 31 - Cleaning, Disinfection, and Sterilization

A hospital is beginning a major construction project. The IP has been asked to join the planning team to assist with the development of the Infection Control Risk Assessment (RCA) for the project. What is the purpose of the ICRA? a. Develop and oversee the construction project schedule b. Minimize infectious hazards for patients and healthcare personnel c. Provide direction for level three and four projects only d. Coordinate systems start-ups

Minimize infectious hazards for patients and healthcare personnel Rationale: An IRCA must guide a strategic, proactive design to mitigate environmental sources of microbes, prevent infectious hazards through architectural design (e.g., hand washing and hand hygiene stations; isolation rooms; materials selection for surfaces and furnishings), and provide control measures that mitigate potential contamination during actual construction or renovation (e.g., dust barriers, pressure differentials, protection of air handlers). Reference: APIC Text, 4th edition, Chapter 116 - Construction and Renovation

Which of the following does not describe indirect contact transmission? a. Mites from a scabies-infested patient b. Equipment that is not cleaned, disinfected, or sterilized adequately between patients c. Food and water supplies that are not prepared and maintained according to sanitation standards d. Inadequate hand hygiene performed by a care provider

Mites from a scabies-infested patient Rationale: Contact transmission is the most common mode of transmission and is divided into two subgroups: direct contact and indirect contact. Indirect transmission involves the transfer of an infectious agent through a contaminated intermediate object or person. Hands of healthcare personnel may transmit pathogens after touching an infected or colonized body site on one patient or a contaminated inanimate object. Transmission may occur if hand hygiene is not performed; if equipment is inadequately cleaned, disinfected, or sterilized; or if there is exposure to contaminated food and water that were not prepared and maintained according to sanitation standards. Mites from a scabies-infested patient are an example of direct contact transmission. Reference: APIC Text, 4th edition, Chapter 21 - Risk Factors Facilitating Transmission of Infectious Agents

When coordinating an active surveillance culture (ASC) plan, the IP should incorporate all of the following recommendations from the CDC except: a. Provide additional personnel to obtain cultures and additional laboratory personnel to process the cultures b. Monitor adherence to Standard Precautions c. Provide a mechanism for communicating results to healthcare providers d. Measure outcome to evaluate the effectiveness of the ASC program and Contact Precautions

Monitor adherence to Standard Precautions Rationale: The infection prevention program should include the following when planning for active surveillance cultures: providing additional personnel to obtain cultures and additional laboratory personnel to process these cultures, ensuring turnaround time for screening results, monitoring adherence to Contact Precautions, providing a mechanism for communicating results to healthcare providers, and measuring outcomes to evaluate the effectiveness of active surveillance cultures and Contact Precautions. Reference: APIC Text, 4th edition, Chapter 29 - Isolation Precautions (Transmission-based Precautions)

All of the following methods for measuring hand hygiene adherence are acceptable except: a. Using electronic systems that allow continuous monitoring over time and automatic data download and analysis b. Monitoring the volume of gloves used per1,000 patient days c. Monitoring adherence to artificial fingernail policies d. Periodically conducting an observational study to determine the rate of adherence (number of hand hygiene episodes performed/number of hand hygiene opportunities) by ward or service

Monitoring the volume of gloves used per 1,000 patient days Rationale: Hand hygiene is a critical component of patient and employee safety. Evaluation and repeated monitoring of hand hygiene practices, as well as healthcare personnel and senior managers' knowledge and perception of the problem of HAI and the importance of hand hygiene at the healthcare facility, is a vital component of any successful hand hygiene campaign. Unobtrusive direct observation of hand hygiene practices by a trained observer is considered the gold standard for evaluating compliance. Electronic systems for the automatic monitoring of hand hygiene compliance are now available and can significantly facilitate data collection. Consumption of hand hygiene products such as soap and alcohol-based hand rub is another useful indicator. Adherence to artificial fingernail policies may also be monitored. Healthcare personnel should receive feedback about defective practices as well as improvement strategies. Reference: APIC Text, 4th edition, Chapter 27 - Hand Hygiene

What type of respiratory protection (mask) is recommended for immune and nonimmune healthcare personnel when caring for a patient with smallpox? a. Surgical mask b. Exam mask c. N95 or higher level respirator d. Procedure mask

N95 or higher level respirator Rationale: Smallpox is a disease caused by variola viruses, members of the Orthopoxvirus genus. Smallpox was eradicated in the 1970s as the result of a massive worldwide immunization program. Because smallpox does not have an animal reservoir and has been eradicated from the human population, the only way that smallpox can occur is as a result of intentional exposure from a bioterrorism attack. A single confirmed case of smallpox would be a global health emergency. Routine smallpox vaccination ended in the early 1970s when smallpox was eradicated; thus, approximately 42 percent of the U.S. population has never been vaccinated against it The length of immunity is unclear; residual immunity varies from person to person, but smallpox immunity is estimated to only last approximately 3 to 5 years for most people (range 1 to 10 years). Revaccinees (those who have been vaccinated in the past and receive a booster) are much more likely to have a sustained immune response than primary vaccinees (those who are receiving the vaccine for the first time). Survivors of the disease achieve lifelong immunity to smallpox. Smallpox may be spread person to person via droplets, aerosol, or even through hand-to-hand contact. Hospitalized patients need to be isolated using Airborne and Contact Precautions. Airborne Precautions require healthcare providers and others to do the following: (1) place patient in a private room with monitored negative pressure in relation to surrounding areas, (2) wear respiratory protection (N95 respirator) when entering the patient room, and (3) limit the transport of the patient from the room, and if movement is absolutely necessary, place a surgical mask on the patient, if possible. In addition to wearing gloves and gown as outlined in Standard Precautions, Contact Precautions also require the following: (1) wear gloves when entering the room, (2) remove gloves before leaving the patient's room, and (3) wash hands immediately with an antimicrobial agent or a waterless antiseptic agent. In addition, wear a gown when entering the room and remove the gown before leaving the patient's environment. Dedicate the use of noncritical patient care equipment to a single patient (or cohort of patients), if possible. Reference: APIC Text, 4th edition, Chapter 29 - Isolation Precautions (Transmission-based Precautions)

Which of the following patients is not at high risk for a healthcare- associated fungal infection? a. Burn patient b. Premature baby in the Neonatal Intensive Care Unit c. Bone marrow transplant patient d. Patient who underwent joint replacement surgery

Patient who underwent joint replacement surgery Rationale: Fungi are increasingly being identified as healthcare-associated pathogens. Patients at high risk for healthcare-associated fungal infections include patients with leukemia, patients with solid tumors and leukopenia, bone marrow transplant patients, injection drug users, patients who have undergone intra-abdominal or cardiothoracic surgery, burn victims, and premature or low birth weight infants. Reference: APIC Text, 4th edition, Chapter 78 - Fungi

All of the following are true and should be communicated to patients before administering influenza vaccination except: a. The vaccine is formulated annually to protect against influenza strains likely to circulate in the United States in the upcoming winter b. Inactivated influenza vaccine contains noninfectious viral components and cannot cause influenza c. Patients who received specific antivirals (i.e., acyclovir, famciclovir, or valacyclovir) within the preceding 24 hours should not receive influenza vaccination d. Fever, malaise, myalgia, and other systemic symptoms can occur after vaccination

Patients who received specific antivirals (i.e., acyclovir, famciclovir, or valacyclovir) within the preceding 24 hours should not receive influenza vaccination Rationale: There is no contraindication for patients receiving the influenza vaccine if they received specific antivirals within the preceding 24 hours. Precautions must be taken when administering the zoster vaccine to patients who have received antivirals (i.e., acyclovir, famciclovir, or vaiacyclovir) 24 hours before vaccination; use of these antiviral drugs should be avoided for 14 days after zoster vaccination. Before administering the influenza vaccine, patients should be informed of the following: 1. The vaccine is formulated annually to protect against influenza strains likely to circulate in the United States in the upcoming winter. 2. Inactivated influenza vaccine contains noninfectious viral components and cannot cause influenza. LAIV can cause nasal congestion, sore throat, and headache for a few days. 3. Respiratory diseases unrelated to influenza vaccination can occur after vaccination. 4. Fever, malaise, myalgia, and other systemic symptoms can occur after vaccination, especially in persons with no prior exposure to influenza vaccine (e.g., young children). However, in placebo-controlled studies, rates were similar between vaccine and placebo recipients. 5. Influenza vaccine should not be administered to persons known to have anaphylactic hypersensitivity to eggs or other components of the vaccine without first consulting a physician. Reference: APIC Text, 4th edition, Chapter 82 - Influenza

Which of the following bioterrorism agents has the highest fatality rate? a. Q fever b. Ricin c. Smallpox d. Severe acute respiratory syndrome (SARS)

Smallpox Rationale: Smallpox is an acute, contagious, and sometimes fatal disease caused by the variola virus (an orthopoxvirus), and marked by fever and a distinctive progressive skin rash. The majority of patients with smallpox recover, but death may occur in up to 30% of cases. Bioterrorism agents can be separated into three categories, depending on how easily they can be spread and the severity of illness or death they cause. Category A agents, which includes smallpox, are considered the highest risk to national security because they: • Can be easily disseminated or transmitted from person to person • Result in high mortality rates and have the potential for major public health impact • Might cause public panic and social disruption • Require special action for public health preparedness Reference: APIC Text, 4th edition, Chapter 120 - Infectious Disease Disasters: Bioterrorism, Emerging Infections, and Pandemics

Which of the following veins, when used for catheter insertion, has been associated with a lower incidence of central line-associated bloodstream infection (CLABSI)? a. Brachial b. Femoral c. Internal jugular d. Subclavian

Subclavian Rationale: According to the CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections, a subclavian site, rather than a jugular or femoral site, should be used in adult patients to minimize infection risk for nontunneled CVC placement. Use of the femoral vein for central venous access in adult patients should be avoide. Reference: APIC Text, 4th edition, Chapter 34 - lntravascular Device Infections

A woman in active labor with confirmed influenza has been admitted to an acute, care facility. Recommendations for preventing influenza transmission between hospitalized infected mothers and their infants include all of the following except: a. The mother should be placed on Droplet Precautions b. The baby should stay in the same room as the mother c. Keep the isolette at least 3 feet away from the mother when she is not interacting with the baby d. The baby should receive formula during the 5-day period following the mother's symptom onset

The baby should receive formula during the 5-day period following the mother's symptom onset Rationale: Pregnant women and infants are at increased risk of hospitalization from influenza complications. Pregnant women with influenza in the Labor and Delivery suite should be placed on Droplet Precautions. The pregnant woman does not need to wear a mask during the time of delivery. Newborn infants of influenza-infected mothers should stay in the same hospital room as the mother, if possible, and should be housed in an isolette when available. The isolette should be placed at least 3 feet from the mother when she is not interacting with the baby. Influenza-infected mothers may breast-feed but should put on a surgical mask and practice hand hygiene before each feeding or other close contact with their infants. These practices should continue for each feeding during the 5-day period following the mother's symptom onset. Reference: APIC Text, 4th edition, Chapter 82 - Influenza

The infection preventionist (IP) receives a call from a nurse who is scheduling a patient for surgery at her ambulatory surgery center. The nurse tells the IP that the patient is colonized with methicillin¬resistant Staphylococcus aureus (MRSA). Which of the following best describes colonization? a. The presentation of clinical signs of illness or inflammation b. An acute bacterial disease caused by an obligate anaerobic, non-spore-forming rod c. The permanent presence of bacteria that is part of the normal flora d. The presence of microorganisms without the signs/ symptoms of an infection

The presence of microorganisms without the signs/symptoms of an infection Rationale: The term colonization generally denotes the presence of a microorganism in the absence of symptoms or deep tissue invasion. Colonizing organisms (e.g., N. gonorrhoeae colonization of pharynx, Salmonella spp. colonization of stool, MRSA colonization of the nares, and yeast in the genital tract) may facilitate transmission to others or may lead to disease in the colonized individual during a disruptive situation (e.g., normal flora out of balance from antimicrobial treatment, invasive device, or wound). Reference: APIC Text, 4th edition, Chapter 24 - Microbiology Basics

Elements of a ventilator-associated pneumonia (VAP) prevention bundle that have been suggested by the Institute for Healthcare Improvement (IHI) include all of the following practices except: a. Elevation of the head of the bed b. Weekly "sedation vacations" and assessment of readiness to extubate c. Peptic ulcer disease prophylaxis d. Deep venous thrombosis prophylaxis

Weekly "sedation vacations" and assessment of readiness to extubate Rationale: VAP in a critically ill patient significantly increases risk of mortality and at a minimum, increases ventilator time length of stay, and cost of care. The IHI Ventilator Bundle is a grouping of best practices that, when applied together, may result in substantially greater improvement. The key components of the IHI Ventilator Bundle are: • Elevation of the head of the bed • Daily "sedation vacations" and assessment of readiness to extubate • Peptic ulcer disease prophylaxis • Deep venous thrombosis prophylaxis • Daily oral care with chlorhexidine Reference: APIC Text, 4th edition, Chapter 36 - Pneumonia

An "antibiotic time out" occurs: a. Daily b. Weekly c. Within 24 to 48 hours of culture results being available d. Within 96 hours of culture results being available

Within 24 to 48 hours of culture results being available Rationale: Much of antimicrobial prescribing is unnecessary or inappropriate. The CDC has advocated implementing taking an "antibiotic time out" (ATO) whereby prescribing clinicians formally assess three pieces of essential information during clinical rounds: correct dosing, duration of therapy, and indication for treatment. An ATO should be taken when culture results are available, usually within 24 to 48 hours. References: Appendix G. In: Brooks K. Ready Reference for Microbes, 3rd edition. Washington, DC: Association for Professionals in Infection Control and Epidemiology, 2012; Moody J, Cosgrove S, Olmsted R, et al. Antimicrobial stewardship: a collaborative partnership between infection preventionists and healthcare epidemiologists. Am J Infect Control 2012 Mar; 40(2):94-95.