This visual abstract has appeared to summarise the findings of our article about tweeting and infection-related conferences (previous post about the article here):
What makes a tweet fly at conferences?
A study just published in ICHE investigates tweeting activity at several IPC / ID / AMR conferences (the 2016 editions of IPS, ID Week, FIS/HIS, and ACIPC). Perhaps the most interesting finding is that including a weblink or tweeting on certain topics (including C. difficile and the media) increase the chances of a tweet being retweeted, whereas, surprisingly, including a picture reduces the changes of a tweet being retweeted.
Cross-specialty engagement with antimicrobial stewardship
Guest blogger Dr Tim Rawson (bio below) writes…
With antimicrobial resistance taking its place alongside climate change on the global political agenda, the role of antimicrobial stewardship in healthcare has come to the forefront. Being a good steward of antibiotics goes beyond simply possessing the technical ability to maintain the effectiveness of antimicrobials. It requires an understanding of why we all, as healthcare providers, should practice stewardship and an ability to confront many of the social and behavioural barriers preventing good practice. Whilst the infection community and some policy makers are now highly engaged with antimicrobial resistance, there is very little evidence to support engagement with AMS-AMR within other clinical specialties.
Social media survey for healthcare professionls: the results
I gave a presentation at ECCMID today on social media use by healthcare professionals (you can download my slides here). Since there isn’t a great deal of data around social media use by healthcare professionals, I thought I’d generate some! I put out this survey a few weeks ago. I was delighted that 749 healthcare professionals took the survey; thanks to everybody who took part.
Autumn 2014 Update
It’s been another busy quarter on the Micro Blog, with posts on Ebola, coverage of Infection Prevention 2014, and updates on multidrug-resistant Gram-negative rods (especially CRE):
- Journal Roundup September 2014: Ebola, Environmental science, and MDR-GNR (Published 15th October 2014)
- Infection Prevention 2014: Some highlights (Published 6th October 2014)
- Universal vs. targeted interventions in infection prevention and control: the case for a targeted strategy (Published 30th September 2014)
- How to assess scientific posters: a practical guide (Published 29th September 2014)
- Tending the human microbiome (Published 25th September 2014)
- Not all resistant Gram-negative bacteria are created equal: Enterobacteriaceae vs. non-fermenters (Published 17th September 2014)
- Acinetobacter contamination: is anywhere safe? (Published 9th September 2014)
- Ebola: PPE and paranoia (Published 3rd September 2014)
- Journal Roundup August 2014: seeking your input (Published 27th August 2014)
- CRE and friends: Q&A (Published 20th August 2014)
- Are contaminated hands more important than contaminated surfaces? (Published 18th August 2014)
- Isolation: the enemy of CRE (Published 13th August 2014)
- My close shave with viral haemorrhagic fever (VHF) (Published 5th August 2014)
- Preventing HCAI: go long or go wide? (Published 29th July 2014)
- How to write a conference abstract…and beyond! (Published 25th July 2014)
- Journal Roundup July 2014 (Published 22nd July 2014)
- Should every body have a silver lining (inside and out)? (Published 15th July 2014)
As ever, if you have any questions, fire away. We love the interaction!
Image credit: ‘Autumn in New York’.
How to write a conference abstract…and beyond!
The Australasian College for Infection Prevention and Control (ACIPC) asked me to give a webinar on writing a conference abstract for an infection prevention and control conference. I thought it would be useful to share the slides (which you can download here), and let you know how it went.
So why bother submitting an abstract to a conference? It’s all about the big speakers on the big stage, right? Wrong. Submitted abstracts delivered through oral and poster presentation is the life blood of the science underpinning our infection prevention and control practice. There’s a useful PLOS blog along these lines here.
It can be pretty daunting to prepare an abstract for a conference if you’ve not done it before, or had a bad experience in the past. So the idea of the webinar was to provide a step-by-step guide to producing a winning conference abstract.
There are a number of hurdles to overecome to get your abstract accepted. You need to tick the ethics box, be transparent with conflicts of interest, decide on appropriate authorship before getting down to the abstract itself. Follow the ‘house rules’ of the conference carefully to avoid your abstract being rejected simply because it’s in the wrong format.
The title of your abstract is especially important; it will be all that many people will read (particularly if it’s bad). I’ve included some illustrations of titles that I think are good, and some that are not so good. The ones in the ‘not so good’ category are by no means bad: these are accepted abstracts from a scientific conference. It’s just that if the authors thought again about a creative, engaging, informative title, I think they’d come up with something difference. (I should add here, that my abstract titles tend to default to really dull because I’m not brave enough to do anything more creative, so who am I to talk!)
When it comes to writing the abstract itself, the following ‘Dos and Don’ts’ should help:
Once the abstract is accepted, it will be time to produce the poster or prepare the slides. Both posters and slides to illustrate talks should be just that – a visual illustration. For me, the text of the abstract should suffice for the text of the poster and, to a lesser degree, the slides. Save the dense text for the paper that should follow.
Finally, if you have any queries about an abstract for a conference, get in touch with the conference organisers. Behind the impersonal abstract submission site will be living, breathing human beings who would love to support you in disseminating your findings for the good of the community.
SHEA 2014 Spring Conference: Out with contact precautions. In with faecal transplantation
The organizing committee of SHEA should be congratulated for putting together an interesting and engaging agenda for their Spring Meeting, based around the recent ICHE special edition. Sadly, I was only able to make it for ‘From MRSA to CRE: Controversies in MDROs’ at the tail end of the meeting.
Global perspective on CRE evolution – Dr Arjun Srinivasan
Dr Srinivasan kicked off with a frankly frightening status update on the ‘nightmare bacteria’. KPC and NDM-producing Enterobacteriaceae have spread globally and rapidly since 2006.1 The prevalence of carbapenem-resistant K. pneumoniae in the US has risen from 1% in 2001 to a whopping 10% in 2011.2 More worryingly, the prevalence of CRE colonization in long-term acute care hospitals (LTACHs) in Illinois was 30% in a recent point prevalence survey.3 Arjun gave some useful perspectives on the mortality associated with CRE. The odds ratio for mortality attributable to CRE was remarkably similar in studies from Israel and the US at around 4 (which is approximately twice that of MRSA).4-6
Arjun made the point that 10% of CRE reported to the CDC are “community-acquired”. I find this hard to believe and I suspect they’d be healthcare-associated if you searched hard enough for risk factors. The picture would be different in areas of really high prevalence like New Delhi or Greece, but I don’t think the US is quite there yet.
Arjun highlighted some practical limitations of implementing strategies to control CRE, in particular around staff cohorting. “Today you’re assigned to work on the unit dedicated to patients with the nightmare bacteria”; not a popular message to our staff.
The key questions from Arjun’s viewpoint are: the focus has been on K. pneumoniae and E. coli, but should Enterobacter be in the mix? Are we doing enough to control CRE (or possibly, too much)? What are the right policy solutions in terms of reporting and guidelines? And finally, can we control CRE? An updated national report from Israel suggests yes.7 But uncontrolled spread elsewhere (e.g. Greece and increasingly Italy) suggest no.
Lab Identification & Surveillance for MDROs – Dr Daniel Diekema
Dr Diekema gave a timely and thoughtful overview of lab diagnostics for MDROs. One problem hampering clear lab diagnosis and surveillance is how to define an MDRO, and MDR-GNR in particular. Do we go by phenotype or by genotype? Clearly, there are arguments either way; there’s a tendency for clinicians to gravitate towards phenotype and scientists towards genotype I think, so we need to look out for our own biases.
The keynote was “don’t throw away the agar plates just yet”. Molecular diagnostics has a role, but it does not replace agar plates. Molecular diagnostics are great, but do not deal with changing epidemiology; struggle with target variability; are expensive; rely on validation of carriage sites; do not tell you about phenotypic susceptibility; have a limit of detection often around a couple of logs; and need to manage shared resistance genes between species, especially for MDR-GNR. Dan concluded by questioning whether molecular diagnostics remain the realm of reference, referral and research labs!
CRE in LTCF, LTACH, Regional Control – Drs Kerri Thom & Michael Lin
Dr Thom gave a rather disturbing overview of the involvement of long-term care facilities (LTCFs) and LTACHs as reservoirs for the spread of CRE. She began by providing evidence, albeit from outbreaks, that standard hand hygiene focus and contact precautions do not control CRE spread.8,9 You need to do more: active surveillance cultures plus cohorting has worked in a number of studies.8,10,11 Several studies suggest a significant LTCF / LTACH reservoir.3,12-14 A study from 2011 carefully studying regional spread of CRE through analysis of inter-facility “social networks” suggests that a connected regional approach to control is required.12
Dr Lin, working in the “CRE battleground of Illinois”3 continued the theme for a regional approach by presenting a regional collaborative to register CRE carriers: the XDRO registry. Dr Lin referred to a successful CRE LTACH bundle, which was presented at ID Week 2013, and provides some hope that CRE can be controlled in LTACHs.
Posters and oral presentations
The SHEA Spring Meeting had some posters for the first time, which was a welcome addition. The highlights from the posters were:
- Dr Lesho: 75 million person years of surveillance in US military yields 300 CRE cases; 1 per 100,000 person years.
- Dr Mann: Sharklett pattern surfaces performed better than copper for reducing bacterial persistence and transfer.
- Southard: Pulsed-xenon UV disinfection of ICU rooms following ALL discharges associated with 20 v 6 cases of unit-attributable CDI.
- Nicole Kenny: If your microfiber is too absorbent, you can forget about a 10 minute contact time.
Four impressive submitted abstracts were presented:
- Dr Assadian performed an RCT of antimicrobial surgical gloves, demonstrating an impressive microbiological reduction – but will this translate to clinical benefit?
- Dr Cluzet found that recurrent MRSA colonization occurred in 40% of 200 patients with uncomplicated MRSA skin and soft tissue infection in the community, and was associated with colonized household contacts and some antibiotics.
- Dr Decker found that CRE colonization duration was a mean 241 days (range 38-649). Worrying, a few patients followed a ‘pos-neg-pos’ colonization pattern, which supports a “once colonized, always colonized” approach.
- Dr Kwon performed a beautiful RCT of Lactobacillus probiotics, but sadly found that it did not reduce GI MDRO colonization or acquisition.
Contact Isolation Precautions: Unanswered Questions – Dr Daniel Morgan
Dr Morgan gave a very balanced and data-led overview of the pros and cons of contact isolation precautions. On the one hand, gloves and gowns are frequently contaminated with MDROs (which would be hands and clothes if no gloves and gowns).15 On the other hand, the somewhat equivocal findings of the BUGG study do not exactly provide resounding support for contact isolation precautions.16 Also, patients under contact precautions have less contact with healthcare personnel, delayed discharge, an increased risk of adverse events, potential for psychological problems, and reduced patient satisfaction. Dr Morgan’s conclusion was complex (matching the data), with a graded approach to contact isolation precautions advocated: CRE > C. difficile > MRSA > VRE.
Success Stories in MRSA Control – Drs Sarah Haessler, Michael Edmond, Steven Gordon and Jeffrey Stark.
This session was not quite what I was expecting. It turns out that all four speakers have stopped using contact precautions for MRSA colonized patients, so this became a collective justification for this practice. The arguments are compelling: none of the speakers’ MRSA rates skyrocketed when they stopped isolating MRSA patients. The alternative approach to traditional contact precautions seems to be a ‘syndromic approach’: basically, only isolate them if they’re oozing. I can see the logic here, but there may be exceptions. For example, MRSA colonized patients with respiratory viruses can enter a “super-spreader” state and would most certainly not be obviously oozing.17 Also, I wonder whether the faculty would feel differently about contact precautions if they were working outside the US in a healthcare system that is mainly composed of 4 and 6 bed bays (like most NHS hospitals)?
Top 10 MDRO Papers – Drs Susan Huang & Ebbing Lautenbach
Dr Huang selected:
- Sivert NHSN data, demonstrating high rates of carbapenem resistance in CLABSI: 23% of Klebsiella, 26% of Pseudomonas and 65% of Acinetobacter.18
- Rutala study showing that reflective paint results in rapidly reduced UVC cycle times and thus improves feasibility.19 (I think there’s probably two views on this study. Either the reflective paint resulted in more reflective bouncing of the UVC around the room and genuinely improved things. Alternatively, the reflective paint could have reflected the UVC directly back to the sensor more rapidly and actually reduced the dose delivered to the microbes on the surfaces.)
- Harris BUGG study, which is testament to securing big funding for definitive studies (though with frustratingly equivocal results).16
- Huang etc universal intervention studies.20-22 Universal chlorhexidine bathing: YES (provided resistance is monitored). Universal mupirocin decolonization: NO!
Dr Lautenbach chose:
- van Nood faecal transplant for preventing C. difficile recurrence.23 ‘Transpoosions’ work, but we need to work on finding the right synthetic bug mix. Dr Lautenbach described the findings of the faecal transplant study as a “penicillin moment”; it’s a concept that could transform medicine.
- Eye Oxfordshire C. difficile whole genome sequencing study: how much CDI is hospital-acquired?24 The study did not consider asymptomatic carriers or environmental contamination and 25% of patient isolates were not available for analysis. So, there was a pretty large potential burden from which hospital-acquisition could have occurred.
- Lin LTACH CRE colonization study.3 30% of patients carried CRE; this figure was 55% in one of the facilities included in the survey.
- Daneman selective decontamination study.25 I can’t help thinking that ‘selective decontamination’ is misnamed: it’s not very selective at all. Perhaps ‘scorched earth decontamination’ would be more accurate. My view is that, regardless of efficacy, we should be giving faecal transplantation before a cocktail of antibiotics. Let’s save the antibiotics for treating infections.
- Gerber community-based antibiotic stewardship cluster RCT, which showed an impressive reduction in broad spectrum antibiotic prescribing.26
Fecal Transplant for C. difficile Infection – Dr Michael Edmond
Dr Edmond gave a passionate and first-hand case for the effectiveness and value of faecal transplantation for recurrent CDI. It’s not a new concept: ‘faecal therapy’ was documented in Chinese medicine in 300AD; the first modern use was in 1957, with impressive results.27 Faecal microbiota transplantation (FMT) cures recurrent CDI by complementing reduced microbiota diversity.28 Indeed, a recent systematic review of FMT reported an overall cure rate of 91% for recurrent CDI.29 The regulatory position is in flux currently, meaning that purchasing carefully tested stool from the ‘brown cross’ (www.openbiome.org) may be more challenging in future. (Indeed, it may even come to DIY FMT, which is possible: first you collect it, then you blend it and then you stick it…) The bottom line is that fresh or frozen, yours or somebody else’s, stool bank or lab donor, NG tube or enema: FMT works for recurrent CDI. The only question is whether it could be a front-line treatment for CDI.
The Microbiome and Its Role in Infection Prevention – Dr Clifford McDonald
Dr McDonald gave a mind-bending talk on the hugely underestimated role of the microbiome in human disease. The gut microbiome is dominated by the Bacteroidetes or Firmicutes, depending on diet; coliforms are surprisingly minor players.30 Antibiotic therapy results in profound disruption of the gut microbiome;31 thus we need to carefully tend the microbiome.32 We need to consider ways to manipulate the gut microbiome for good, using perhaps ‘advanced’ probiotics or modulating bacterial inter-cell communication. Cliff finished with a thought-proving vision of the future involving extensive testing of the patient’s microbiome, a “tending” consultation and treatment with a course of the appropriate advanced probiotic therapy.
Pro-Con: Should We Be Bare Below the Elbows? Drs Michael Edmond & Neil Fishman
The recently published SHEA guidelines on attire provide some useful background.33 Dr Edmond began with the pro position: clothing becomes contaminated with MDROs, which can be transmitted from clothing in laboratory studies; white coats are rarely washed; there is limited evidence but potential benefit. When evidence is limited, we need to avoid ‘methodolatry’, the worship of the hallowed RCT. It seems that a doctor’s appearance is the least important performance measure from a patient’s viewpoint.34 They are much more concerned with whether their doctor knows their stuff. Perhaps the most powerful argument of all for the pro is that Dr Edmond recently won an award for the best beside manner whilst dressing down.
Dr Fishman began his con in entertaining fashion: by undressing to bare below the elbow and replacing his neck tie for a fetching bow-tie. His argument was: unattractive bingo wings; bug-trapping hairy arms; may be some unintended harm; reduced patient experience; is it consistent when you consider policies for hand-held electronics; and, of course, no evidence.
The UK has been bare below the elbow for several years now. There has been some resistance: in fact, the debate reminded me of a London surgeon going apoplectic when the Prime Minister’s camera crew were not bare below the elbow during a hospital visit. So, should we be bare below the elbow? In my view, yes; it makes it easier to wash your hands. However, the manner in which you interact with you patient is far more important than what you wear.
- Can we control CRE and, if so, how?
- Related to this, how to deal with the (apparently sizable) CRE reservoir in LTACHs?
- Do molecular diagnostics remain the realm of reference, referral and research labs?
- Has our focus on CRE taken our eye off multidrug-resistant non-fermenters (particularly A. baumannii), which are a greater ‘clear and present danger’ for many facilities?
- Can we risk abandoning contact precautions for MRSA patients? In a US hospital with 100% single rooms, perhaps. In the NHS composed of 4 and 6 bed bays, no.
- FMT works for recurrent CDI and regulators should not block access to it.
- Could FMT work as a front-line treatment for CDI?
- How can we modify the gut microbiome most effectively to confer infection prevention and control benefits?
- Is microbiome modulation more effective than antibiotic ‘selective decontamination?
1. Molton JS, Tambyah PA, Ang BS, Ling ML, Fisher DA. The global spread of healthcare-associated multidrug-resistant bacteria: a perspective from Asia. Clin Infect Dis 2013; 56: 1310-1318.
2. Centers for Disease C, Prevention. Vital signs: carbapenem-resistant Enterobacteriaceae. MMWR Morb Mortal Wkly Rep 2013; 62: 165-170.
3. Lin MY, Lyles-Banks RD, Lolans K et al. The importance of long-term acute care hospitals in the regional epidemiology of Klebsiella pneumoniae carbapenemase-producing Enterobacteriaceae. Clin Infect Dis 2013; 57: 1246-1252.
4. Cosgrove SE, Sakoulas G, Perencevich EN, Schwaber MJ, Karchmer AW, Carmeli Y. Comparison of mortality associated with methicillin-resistant and methicillin-susceptible Staphylococcus aureus bacteremia: a meta-analysis. Clin Infect Dis 2003; 36: 53-59.
5. Patel G, Huprikar S, Factor SH, Jenkins SG, Calfee DP. Outcomes of carbapenem-resistant Klebsiella pneumoniae infection and the impact of antimicrobial and adjunctive therapies. Infect Control Hosp Epidemiol 2008; 29: 1099-1106.
6. Borer A, Saidel-Odes L, Riesenberg K et al. Attributable mortality rate for carbapenem-resistant Klebsiella pneumoniae bacteremia. Infect Control Hosp Epidemiol 2009; 30: 972-976.
7. Schwaber MJ, Carmeli Y. An ongoing national intervention to contain the spread of carbapenem-resistant enterobacteriaceae. Clin Infect Dis 2014; 58: 697-703.
8. Palmore TN, Henderson DK. Managing Transmission of Carbapenem-Resistant Enterobacteriaceae in Healthcare Settings: A View From the Trenches. Clin Infect Dis 2013; 57: 1593-1599.
9. Kochar S, Sheard T, Sharma R et al. Success of an infection control program to reduce the spread of carbapenem-resistant Klebsiella pneumoniae. Infect Control Hosp Epidemiol 2009; 30: 447-452.
10. Agodi A, Voulgari E, Barchitta M et al. Containment of an outbreak of KPC-3-producing Klebsiella pneumoniae in Italy. J Clin Microbiol 2011; 49: 3986-3989.
11. Ben-David D, Maor Y, Keller N et al. Potential role of active surveillance in the control of a hospital-wide outbreak of carbapenem-resistant Klebsiella pneumoniae infection. Infect Control Hosp Epidemiol 2010; 31: 620-626.
12. Won SY, Munoz-Price LS, Lolans K et al. Emergence and rapid regional spread of Klebsiella pneumoniae carbapenemase-producing Enterobacteriaceae. Clin Infect Dis 2011; 53: 532-540.
13. Marquez P, Terashita D. Editorial commentary: long-term acute care hospitals and carbapenem-resistant Enterobacteriaceae: a reservoir for transmission. Clin Infect Dis 2013; 57: 1253-1255.
14. Marchaim D, Perez F, Lee J et al. “Swimming in resistance”: Co-colonization with carbapenem-resistant Enterobacteriaceae and Acinetobacter baumannii or Pseudomonas aeruginosa. Am J Infect Control 2012; 40: 830-835.
15. Morgan DJ, Liang SY, Smith CL et al. Frequent multidrug-resistant Acinetobacter baumannii contamination of gloves, gowns, and hands of healthcare workers. Infect Control Hosp Epidemiol 2010; 31: 716-721.
16. Harris AD, Pineles L, Belton B et al. Universal glove and gown use and acquisition of antibiotic-resistant bacteria in the ICU: a randomized trial. JAMA 2013; 310: 1571-1580.
17. Sheretz RJ, Reagan DR, Hampton KD et al. A cloud adult: the Staphylococcus aureus-virus interaction revisited. Ann Intern Med 1996; 124: 539-547.
18. Sievert DM, Ricks P, Edwards JR et al. Antimicrobial-resistant pathogens associated with healthcare-associated infections: summary of data reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2009-2010. Infect Control Hosp Epidemiol 2013; 34: 1-14.
19. Rutala WA, Gergen MF, Tande BM, Weber DJ. Rapid hospital room decontamination using ultraviolet (UV) light with a nanostructured UV-reflective wall coating. Infect Control Hosp Epidemiol 2013; 34: 527-529.
20. Climo MW, Yokoe DS, Warren DK et al. Effect of daily chlorhexidine bathing on hospital-acquired infection. N Engl J Med 2013; 368: 533-542.
21. Milstone AM, Elward A, Song X et al. Daily chlorhexidine bathing to reduce bacteraemia in critically ill children: a multicentre, cluster-randomised, crossover trial. Lancet 2013; 381: 1099-1106.
22. Huang SS, Septimus E, Kleinman K et al. Targeted versus Universal Decolonization to Prevent ICU Infection. N Engl J Med 2013; 368: 2255-2265.
23. van Nood E, Dijkgraaf MG, Keller JJ. Duodenal infusion of feces for recurrent Clostridium difficile. N Engl J Med 2013; 368: 2145.
24. Eyre DW, Cule ML, Wilson DJ et al. Diverse sources of C. difficile infection identified on whole-genome sequencing. N Engl J Med 2013; 369: 1195-1205.
25. Daneman N, Sarwar S, Fowler RA, Cuthbertson BH, Su DCSG. Effect of selective decontamination on antimicrobial resistance in intensive care units: a systematic review and meta-analysis. Lancet Infect Dis 2013; 13: 328-341.
26. Gerber JS, Prasad PA, Fiks AG et al. Effect of an outpatient antimicrobial stewardship intervention on broad-spectrum antibiotic prescribing by primary care pediatricians: a randomized trial. JAMA 2013; 309: 2345-2352.
27. Eiseman B, Silen W, Bascom GS, Kauvar AJ. Fecal enema as an adjunct in the treatment of pseudomembranous enterocolitis. Surgery 1958; 44: 854-859.
28. Chang JY, Antonopoulos DA, Kalra A et al. Decreased diversity of the fecal Microbiome in recurrent Clostridium difficile-associated diarrhea. J Infect Dis 2008; 197: 435-438.
29. Sha S, Liang J, Chen M et al. Systematic review: faecal microbiota transplantation therapy for digestive and nondigestive disorders in adults and children. Aliment Pharmacol Ther 2014; in press.
30. De Filippo C, Cavalieri D, Di Paola M et al. Impact of diet in shaping gut microbiota revealed by a comparative study in children from Europe and rural Africa. Proc Natl Acad Sci U S A 2010; 107: 14691-14696.
31. Dethlefsen L, Relman DA. Incomplete recovery and individualized responses of the human distal gut microbiota to repeated antibiotic perturbation. Proc Natl Acad Sci U S A 2011; 108 Suppl 1: 4554-4561.
32. Tosh PK, McDonald LC. Infection control in the multidrug-resistant era: tending the human microbiome. Clin Infect Dis 2012; 54: 707-713.
33. Bearman G, Bryant K, Leekha S et al. Healthcare personnel attire in non-operating-room settings. Infect Control Hosp Epidemiol 2014; 35: 107-121.
34. Aitken SA, Tinning CG, Gupta S, Medlock G, Wood AM, Aitken MA. The importance of the orthopaedic doctors’ appearance: a cross-regional questionnaire based study. Surgeon 2014; 12: 40-46.
ICHE special edition on the role of the environment in transmission
Infection Control and Hospital Epidemiology have dedicated their May issue to articles investigating the role of contaminated surfaces in the transmission of pathogens. There’s an awful lot of good stuff here, but this is my take on the key findings of the studies:
- Drs Weber and Rutala write a thoughtful introduction covering the highlights of the issue.
- A study from the University of Maryland shows that admission to a room previously occupied by a patient with ESBL-producing Gram-negative bacteria does not increase the risk of acquisition. This is a surprise because this association has been shown for other pathogens including MRSA, VRE, C. difficile and, most interestingly, other Gram-negatives such as A. baumannii and P. aeruginosa. I suspect this difference is explained by the fact that the Enterobacteriaceae are less able to survive on dry hospitals surfaces than the lactose non-fermenting Gram-negatives such as A. baumannii.
- Research from the Cleveland VA tells a fascinating story of sequential interventions to reduce environmental contamination with C. difficile. The introduction of fluorescent marking with feedback did not eliminate the C. difficile environmental contamination, with 50-60% of cultures remaining contaminated. Similarly, the introduction of a UVC no-touch room disinfection system for terminal disinfection did not solve the problem, with 30-40% of cultures remaining contaminated. Only when daily disinfection was performed by a dedicated team and terminal disinfection was performed by EVS supervisors and/or the infection control team was the problem finally solved and C. difficile could no longer be cultured from surfaces. This study shows firstly how a combination of interventions can be useful, and secondly, the extraordinary lengths required to eliminate C. difficile spores from the environment.
- An in situ evaluation of a UVC room disinfection device at Duke / University of North Carolina shows that UVC decreases but does not eliminate key pathogens MRSA, VRE and C. difficilefrom the hospital environment.
- A study from Johns Hopkins shows that the packaging of 7-9% of supply items was contaminated with MDROs, and that hydrogen peroxide vapor (HPV) is effective for the disinfection of the supply packaging. The cost of supplies discarded from six ICUs amounted to almost $400,000, not including the costs associated with waste disposal. Hence, the practice of disinfecting the packaging of supplies using HPV would generate substantial cost savings.
- The long-awaited copper study is a multi-centre evaluation of the clinical impact of introducing 6 copper alloy high-touch sites into the rooms of patients on three ICUs. Patients were randomized to intervention copper rooms and control non-copper rooms. Patients admitted to copper rooms were significantly less likely to acquire healthcare-associated infection or colonization with MDROs. The authors also make an interesting association between the degree of contamination in patient rooms and the risk of acquisition. However, since sampling was performed weekly regardless of a patient’s infection or colonization status, it is not possible to determine whether this association is causal or simply due to the fact that infected / colonized patients are likely to shed more bacteria into the hospital environment. The scale of the difference is surprising, with a 50% difference between the groups. I am “a believer” in the role of the environment in transmission, but a 50% reduction attributable to 6 copper alloy surfaces does seem rather high. But it does seem that the introduction of copper surfaces does reduce transmission. Questions remain over the practicality and durability of the widespread adoption of copper alloy surfaces in healthcare.
- Another University of Maryland study with a powerful cluster randomized controlled trial design shows convincingly that enhanced daily cleaning reduces MRSA and MDR A. baumanniicontamination of the gloves and gowns of healthcare personnel when they exit the rooms of patients on precautions with these pathogens. Now, in theory, healthcare personnel should discard the gowns and effectively disinfect their hands. However, since we know that this doesn’t always happen, these reductions are likely to be meaningful.
- A study shows that N95 filters to their job and capture infectious influenza aerosols. However, in the event of an influenza pandemic, how long will the stockpile of N95 (FFP3) masks last?
- An extensive microbiology survey from UCLH in London found that the sites closest to the patient were more likely to be contaminated regardless of ward setting. However, in ICUs, sites touched by staff were more likely to be contaminated whereas in gastrointestinal wards with mobile patients, sites touched by patients were more likely to be contaminated.
- A short review by Carling and Huang explores evolving issues in how to tackle the contaminated healthcare environment.
- A novel review piece by a team from Georgia, Maryland and Washington DC provides an overview of how evidence-based design can help to prevent and control the transmission of healthcare-associated pathogens.
- A study from Florida found that 10% of rooms were contaminated with A. baumannii even when the current occupant was not known to be infected or coloinsed. This could be due to unrecognized infection or colonization, survival from a prior room occupant or important by a the patient, a visitor or healthcare personnel.
- A study from New Haven, Connecticut found that a new activated hydrogen peroxide containing wipe was highly effective for achieving a hygiene standard of <2.5 cfu / cm2, with 75% of sites yielding no growth at all.
- A new study from the Cleveland VA shows the value of investing time and resource in observing and supervising cleaning practices in hospitals. Direct supervision of cleaning staff was required to achieve optimal results. The concern is what happens when the direct observation becomes routine or stop all together? Will good practice continue?
- One of the problems with UV radiation for hospital room disinfection is poor reflectivity from some hospital materials, contributing to reduced efficacy out of direct line of sight and influencing cycle times. An innovative study resulting from a collaboration between healthcare experts at the University of North Carolina and chemical engineers at the University of North Dakota found that using paint that reflects UV more effectively reduces cycle times to achieve comparative efficacy for UV room disinfection.
- A study from South Carolina provides some further microbiological support for the clinical impact associated with copper surfaces, showing that copper alloy bedrails are associated with significantly lower bioburden than plastic bed rails.
- A useful study from Ireland tells the story of laboratory optimization of sampling methods, which successfully recovered ESBL producing K. pneumonaiaefrom hospital surfaces.
- A John Hopkins study provided some promising data of a mobile “UV wand” for the disinfection of hospital surfaces. The device a achieve a 1-log reduction of microbial contamination, and may provide a useful adjunctive approach to hospital disinfection.
- Some Australian data raised some important questions about the reliability of ATP systems. The relative light unit readings for a dilution series of synthetic ATP were compared against an HPLC gold standard for three ATP systems. Substantial variation was noted for all systems, indicating that RLU values are more indicative than absolute.
- All but one of the studies in this issue have been in the acute healthcare setting. A study from New York bucks the trend, evaluating S. aureus contamination in maximum security prisons. There did not seem to be an obvious association between S. aureus infection and contamination. If anything, the rates of contamination of inmates and their environment was surprisingly, relative to high rates of colonization with MRSA identified in other studies.
- Yet more research from the Cleveland VA evaluates a novel disinfectant: an electrochemically activated saline solution, also known as ‘superoxidized water’. Surprisingly, the novel disinfectant performed comparably to 10% bleach for the inactivation of C. difficile in vitro, and eliminated C. difficile contamination from hospital surfaces when applied in situ. This agent should be prioritized for further evaluation.
- Finally, a French study reports a case of catheter-related bloodstream infection related to a preoperative shower with P. aeruginosa contaminated water. Something to think about next time you have a shower.
The quality and importance of the research in this article has impressed me. However, the fact is that some of the basic questions about the role of the environment in transmission and the most cost effective interventions are yet to be answered. But we’re moving in the right direction.