Curtis Donskey’s group recently published a multicentre randomised trial in 16 US hospitals to evaluate the impact of an enhanced cleaning programme (including fluoruescent markers, environmental cultures, and feedback to cleaners) on the transmission of C. difficile. The intervention resulted in an increase in the removal of fluorescent markers, a reduction in environmental contamination with C. difficile, but no reduction in healthcare-associated CDI!
disinfection
Cleaning and disinfection survey
See below details of a survey that you may find interesting to complete. I had a small role in providing some feedback on an earlier version of this survey and I hope it will serve to highlight areas that require more thought and / or research…
On behalf of the International Society of Chemotherapy (ISC) working group on Infection Prevention we would be grateful if you could complete this anonymous survey.
HIS Spring Meeting: ‘Contaminated surfaces: the missing link’
Thought I’d share some key points from the 2016 HIS Spring Meeting.
Outlining the problem(s)
Prof Gary French kicked off the meeting with a (sic) historical perspective, describing how the perceived importance of the environment in transmission has oscillated from important (in the 40s and 40s) to unimportant in the 70s and 80s to important again in the 2000s. Gary cited a report from the American Hospital Association Committee on Infections Within Hospitals from 1974 to prove the point: ‘The occurrence of nosocomial infection has not been related to levels of microbial contamination of air, surfaces and fomites … meaningful standards for permissible levels of such contamination do not exist.’ Gary covered compelling data that contaminated environmental surfaces make an important contribution to the transmission of Gram-positive bacteria and spores, highlighting that C. difficile in particular is a tricky customer, not helped by the fact that many ‘sporicides’ are not sporicidal!
What are we doing to improve hospital room cleaning and disinfection?
I gave a webinar last week for 3M (you can download my slides here) on “Your hospital room can make you sick: How improved cleaning and disinfection can help”. I asked the audience what they were doing to improve cleaning and disinfection, and thought I would share the findings. I don’t know the exact size of the audience (but it’s usually a couple of hundred mainly US based IPC folks), and the audience were allowed to choose any answers that applied to them for the second two questions.
The room lottery: why your hospital room can make you sick
In this era of increasing patient choice, let’s imagine you were offered the choice between two identical looking hospital rooms. Your chances of picking up a multidrug-resistant organism (MDRO) are approximately doubled if you choose the wrong room. But you have no way of knowing which room is safest.
So what explains this lottery? The key information you have not been told is the MDRO status of the previous room occupants. One of the rooms was previously occupied by a patient with C. difficile, and if you choose this room, your risk of developing C. difficile infection doubles. And it’s not just C. difficile – this same association has been demonstrated for MRSA, VRE, Acinetobacter baumannii and Pseudomonas aeruginosa. Underpinning this association is the uncomfortable fact that cleaning and disinfection applied at the time of patient discharge is simply not good enough to protect the incoming patient.
Reflections from Infection Prevention 2015 Part III: Thinking outside the box
For the third and final installment of my blog-report from Infection Prevention 2015, I thought I’d cover some of the more innovative approaches in and around the IPC sphere:
Part II: Improving the systems
Part III: Thinking outside the box
New technology to improve hand and environmental hygiene
I for one am pretty sick of seeing unrealistically high levels of hand hygiene compliance being reported from peer-to-peer manual auditing approaches. One way to get more realistic compliance data is through automated approaches to hand hygiene compliance, reviewed here by Drs Dawson (Warwick) and Mackrill (Imperial College London), who also presented their findings at the conference, and by another group here. Drs Dawson and Mackrill considered issues around product usage, self-reporting, direct observation, perceptions of technology (often viewed, unhelpfully, as a ‘silver bullet’), and staff perceptions of need and benefit. They divided the technology into those that monitored product usage, surveillance systems that monitored individual performance, and systems that monitored both product usage and individual performance. Although automated surveillance systems will always be imperfect and involve a degree of inference, would you rather monitor the 5 moments sporadically / badly or have robust measurements of a smaller number of moments? Automated surveillance methods will not replace manual audits – at least for now – but it’s time to take a long hard look at what is available.
How can we stop nursing homes nurturing MRSA?
There is an emerging feeling that we need to start spreading the focus of infection prevention and control beyond acute hospitals. There has always been a sense that standards of infection control outside of acute settings are, shall we say, “different” to acute hospitals (aka non-existent) so it’s great to see a study of an infection control intervention in nursing homes.
The study was a cluster randomised controlled trial of MRSA screening, decolonisation and enhanced environmental disinfection vs. standard precautions in 104 of 157 nursing homes in a Swiss region. The authors chose a rather unusual, pragmatic endpoint of the prevalence of MRSA colonisation after 12 months.
Biofilms make the hospital environment far from ‘inanimate’
Anybody doubting that biofilms really do exist on dry hospital surfaces needs to read this study: biofilms are there, they are complex, and they are common. A landmark study by the same Australian Vickery group published in 2012 first identified biofilms on a handful of dry hospital surfaces in an ICU. But this study is far more comprehensive and convincing.
What’s lurking in the hospital environment? The importance of cleaning and disinfection in infection prevention and control
I was asked to speak to a group of link nurses at Southampton Hospital earlier in the week, and thought I’d share my slides, here.
I am passionate about the importance of surface contamination in transmission: I still think it’s really under-rated. I am pretty sure that most healthcare workers would have no idea that your chances of acquiring C. difficile infection (and others) is influenced by who used the room or bed space before you. And who would believe that VRE could survive on a dry surface for 4 years? Or that touching a surface is as important as touching the patient in terms of acquiring contamination on your hands?
Probiotics for environmental cleaning – can’t B. cereus
Vandini et al. (1) evaluate the effect of a microbial cleaner, containing spores of food grade Bacillus subtilis, Bacillus pumilus and Bacillus megaterium in two Italian and one Belgium hospital.
According to the abstract 20,000 microbiological samples were taken from surfaces, during the 24-week investigation, which would equal approximately 120 samples per day!
While nothing about blinding or block-randomization (or any possible approach that would eliminate bias) was mentioned, it is stated that the cleaning staff was not aware which cleaning product they used. Seen the fact that chlorine based-cleaners were the standard products in the two Italian hospitals, this seems hard to believe. The study period started at different times in the hospitals (but not by design) and in opposite to the abstract for different periods of time, namely 6, 24, and 66 weeks, respectively.
Reflections on Infection Prevention and Control 