What’stheenvironmentgottodowithit?

MichaelParry,MD,FACP,FIDSA,FSHEAThomasJayBradsell ChairofInfectiousDiseases,StamfordHospital

ProfessorofClinicalMedicine,ColumbiaUniversityCollegeofPhysiciansandSurgeons

GoldenRulesofInfectionPrevention

hand hygiene

environmentalhygiene

engineered processes of care

HandHygiene

Bundleimplementation(SSIprevention)• Pharmacologic

– Mechanicalbowelprep– Oralantibioticsthedaypriortosurgery(Correctdrugs,doses)– Prophylacticintravenousantibiotics(Appropriateselection,timing,re-

dosing,postoplimitation)• NonPharmacologic

– Preoperativeshowers– Appropriatehairclipping– Appropriateskinprep– Maintainbodytemperature– Postoperativeoxygenation– Laparoscopicwhenpossible

• Technical– Reduceintraoperativecontamination-- minimizespillage– Maintain“clean”areasseparatefromcontaminated– Changegloves,gowns,suction,bovie tip– Protectsuperficialwound– Recognizehighrisksituations-- Delayedprimaryclosure

• Systematic– Time-out– Checklist– Debriefingform– Quarterlydatareview

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Contaminatedsurfaces

• 70%ofsurfacesincolonizedpatients’roomsarecontaminatedwithMRSAorVREorC.difficile.– Countertops– Bedrails– Equipment– Telephone,callbutton

• MorethanhalfthepatientswhobecamecolonizedwithMRSAafterenteringtheICUacquireastrainNOT presentonotherpatientsthereatthetime.

• Oncecaregiverstouchthesesurfaces,theirhandsorglovesarecontaminated.

Infection Control and Hospital Epidemiology (v. 9, 1997) 622-627.Infection Control and Hospital Epidemiology (v.20.2, 2006).

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SurvivalofMulti-drug-resistantOrganismsintheEnvironment

• DurationofsurvivalofMRSAindryconditions– Plasticcharts=11days– Laminatedtabletop=12days– Clothcurtains=9days

• EnvironmentalsurvivalofVRE– Upholstery,furnitureandwallcoverings=7days

• SurvivalofClostridiumdifficile– Months

Huang et al, Infect Control Hosp Epidemiol 2006;27:1267-1269Lankford et al, Am J Infect Control2006;34:258-263

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Contamination of Computer Keyboards

Beforecleaning

Aftercleaning

Keyboards,Telephones,Equipment–allharborStaph,Strep,andotherPathogens

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Manypersonneldon’trealizewhentheyhavemicroorganismsontheirhands

Nurses,doctorsandotherhealthcareworkerscangetthousandsofbacteriaontheirhandsbydoingsimpletasks,like

• pullingpatientsupinbed• takingabloodpressureorpulse• touchingapatient’shand• rollingpatientsoverinbed• touchingthepatient’sgownorbedsheets• touchingequipmentlikebedsiderails,over-bedtables,IVpumps

Cultureplateshowinggrowthofbacteria24hoursafterhandplacedontheagarplate

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RoleofasymptomaticcarriageofCdifficile inpatientsataLTCFRiggs,etal.ClevelandClinic,2007.

• 68asymptomaticpatientsinLTCF• 51%carriersofC.difficile

– 49%ofthesehadNAP-1strain

• Carriershadhighskin(61%)carriage– versus70%inCDIcases

• Carriershadhighenvironmental(59%)contamination– Versus70%inCDIcasesand20%innon-carriers

• PriorCDIandrecent(<3mo)antibioticusewasassociatedwithcarriage

• 20%ofcarriersdevelopedCDIover4mofollow-up

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Wherearethegerms?

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Wherearethegerms?

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TheChallenge:tocreateaneffectiveenvironmentalhygieneprogram

• CleaningPolicies&Procedures– Everyone’sjob!– Dailycleaningandterminalcleaning– Hightouchsurfacesfocus– Equipmentcleaning– “Rollingstock”management– Unitcorecleaning

• Staffneededucationonanongoingbasis.• Checklistforroomcleaning• Roomturn-overtimeforanisolationpatienttakes

approximately45-60minutes.• Staffshouldberoutinelyevaluatedonperformance

– DirectandClandestineobservation

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ElementsoftheInterdisciplinaryCleaningandDisinfectionInitiative

• ProgramimplementedOctober,2005• Useofafluorescentmarkertodetect

surfacecleaning• Collaborativeevaluationofcleaningprocess• Nursingserviceperformedcleaning

assessments• Ongoingevaluationofeffectiveness

– Groupfeedbacktohousekeepingdepartmentatlarge

– Personalfeedbackonindividualperformancetomanager

• Incorporationintoperformancemanagementprocess

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EnvironmentalSitesTesting

• Toiletseat• Toilethandle• Toilethandhold• Sink• Sinkfaucethandle• BRdoorknob• BRlightswitch• Telephone• TVcontrol/callswitch• Siderails• Traytable• Bedsidetable• Chairhandrail• Roomdoorknobs

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EnvironmentalCleaningSHOverallProgress

Percentofsurfacescleaned

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0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

perc

ent c

lean

ed

Percent of surfaces cleaned 10/12 to 6/15

IncidenceofHospital-acquiredClostridiumdifficile Infection.

Leffler DA, Lamont JT. N Engl J Med 2015;372:1539-1548

DifficultiesincontrollingthespreadofC.difficile

• Highcommunityprevalence– especiallyLTAC(30-50%);SNF(10-20%);community(3-6%)

• Difficultypreventinginfectioninhighrisksettings– “incidentdensity”pressure– carriers+ill

• Hospital“onset”versushospital“acquisition”• Antibioticuseandthemicrobiome

– necessaryandunnecessary– breadthandlengthandtypeofrx

• Prevalenceofacidsuppressiontherapy– VAPprevention;otherordersets

• Prolongedfecalandskincarriage– Clinicallysuccessfultreatmentdoesn’teradicatethespore

• Frequentrecurrence– Treatment,ageandimmunocompetence dependent

• Persistenceofsporesintheenvironment– Resistancetogermicides– Patientingestion

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PersistenceofC.difficileDuringandAfterTreatment

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10

20

30

40

50

60

70

80

90

100

Prior to treatment Day 3 of treatment Resolution of diarrhea

End of treatment 1-6 weeks after treatment

Perc

ent P

ositi

ve

Percentage of positive cultures for C. difficile before, during, and after treatment

Stool Skin Environment

Wafa Al Nassir, et al. Cleveland VA. ICHE, 2010

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StamfordHospital-acquiredC.difficile

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C.difficile bundle• Environmentalcleaningprogram• Bleach/peracetic acidprogram• Dailyandterminalcleaning• IsolationforCdiff

– GownandGlove– Soapandwater– Durationofhospitalization

• Rapiddetection– PCR– Isolatefordiarrhea– Readmissionflag

• Dedicatedequipment– Yellowstethoscopes;disposableBPcuffs,thermometers,etc– Norectaltemperatures

• Treatmentinitiatives– vancomycinandfidaxomycin• PPIreductioninitiative• Antibioticstewardshipprogram• Fecaltransplantationprogram• NewHospitalinitiatives

TheNewStamfordHospital

Whathelpisonthehorizon?

• Antimicrobialsurfaceengineering– Copper,silver– Nanotechnology– Fabrics(curtains,scrubs,linens)

• UVlightandotherlighttechnologies• Aerosols• Focusonthemicrobiome

– Fecaltransplantation– Syntheticstool– Alternativetreatmentmodalities

• Focusontheimmunesystem– Monoclonalantibodies– Immunization

MicrobialLoadonEnvironmentalSurfaces:TheRelationshipBetweenReducedEnvironmentalContaminationandReductionofHealthcare-AssociatedInfections(TheBETRDisinfectionStudy)

IDWEEKAbstract262,2016

WILLIAMRUTALA,etalUniversityofNorthCarolinaHealthCare,ChapelHill,NC

Background:Disinfectionofnoncriticalenvironmentalsurfacesandequipmentisanessentialcomponentofinfectionpreventionassurfacesmaycontributetocross-transmissionofepidemiologicallyimportantpathogens(EIPs).

Results: Enhanceddisinfectioninterventions(i.e.,Quat/UV,Bleach,Bleach/UV)weresignificantlysuperiortoaQuat aloneinreducingEIPs.

Conclusion:Comparisonofthebeststrategywiththeworststrategy(i.e.,Quat vsQuat/UVorBleach/UV)revealedthatareductionof>90%inEIPsledtoa35%decreaseinsubsequentpatientcolonization/infection.Ourdatademonstratedthatadecreaseinroomcontaminationwasassociatedwithadecreaseinsubsequentpatientcolonization/infection.

AntimicrobialActivityofaContinuousVisibleLightDisinfectionSystem

IDWEEKAbstract267,2016

WILLIAMRUTALAandDANIELSEXTON,etal.UniversityofNorthCarolina,ChapelHill,NCandDukeUniversityMedicalCenter,Durham,NC

Background:Anoverheadlightfixturetechnology,whichcontinuouslyandsafelydisinfectstheenvironmentwasassessedtodeterminetheeffectivenessforthereductionofEIP. Thistechnologycreatesanarrowbandwidthofhigh-intensityvisiblebluelightwithapeakoutputof405nmthatgeneratesreactiveoxygenspeciesandkillsmicroorganisms.

Results:Theseresultsdemonstratedthatthe405nmlightinactivatedthreevegetativebacteria(MRSA,VRE,MDRA)onsurfaceswithcontacttimesof1-96hr.Statisticaldifferences(p<0.05)wereobservedusingbluelightforVREat24hr,forMRSAat3-7hr,forMDRAat5-24hr,andforC.difficile sporesat5hrand72hr.Theinactivationwasmoresignificantwhenthesurfaceirradiancewasincreasedbyaddingthebluelight.

Conclusion: Highintensitylighttechnologycouldbeconsideredforseveralhealthcaredecontaminationapplications

ReducedHealthcareAssociatedInfectionsinanAcuteCareCommunityHospitalusingaCombinationofSelf-DisinfectingCopper-ImpregnatedCompositeHardSurfacesandLinens

IDWEEKAbstract263,2016

COSTISIFRI,MD,KYLEENFIELD,MDandGENEBURKEMD.UniversityofVirginiaHealthSystemandSentaraHealthcare,Norfolk,VA

Background:Effortstodecreaseenvironmentalbioburden areassociatedwithreducedtransmissionofmicrobialpathogensanddevelopmentofHAIs.Copperoxidehaspotentbiocidal activity.Herewereporttheresultstrialofacopperoxide-impregnatedcompositeproductincorporatedintohospitalcountertops,moldedsurfaces,patientgownsandlinens.

Results:Thestudywasconductedovera25.5-monthtimeperiod.HAIratesobtainedfromthecopper-containingnewtower(72beds;14,479patient-days)andtheunmodifiedhospitalwing(84beds;19,177patient-days)werecomparedtothosefromthebaselineperiod(204beds;46,391patient-days).Thenewtowerhad78%(P=.023)fewerhealthcare-associatedinfectionsduetoMDROsorC.difficile ,83%(P=.048)fewercasesofC.difficile infection,and68%(P=.252)fewerinfectionsduetoMDROsrelativetothebaselineperiod.Nochangesinratesofhealthcare-associatedinfectionswereobservedintheunmodifiedhospitalwing.

Conclusion:Copperoxide-impregnatedcompositehardsurfacesandlinensmaybeusefultechnologiestopreventhealthcare-associatedinfectionsintheacutecarehospitalsetting.

TheAntisepticScrubContaminationandTransmission(ASCOT)TrialtoDeterminetheImpactofAntiseptic-

ImpregnatedScrubsonHealthcareWorkerContaminationIDWEEKAbstract1351,2016

DEVERICKANDERSON,MDetal.DukeInfectionControlOutreachNetwork,DukeUniversityMedicalCenter,Durham,NC

Background:HCPclothingbecomescontaminatedduringpatientcareandcanserveasavectorforsubsequenttransmission. Antimicrobial-impregnatedclothingmayreducecontamination,butclinicaldataarelacking.

Methods:Scrubsimpregnatedwith(1)acomplexelementcompoundwithasilver-alloy,or(2)anorganosilane-basedquaternaryammoniumandahydrophobicfluoroacrylate copolymeremulsion,werecomparedtotostandardcotton-polyscrubsduringclinicalcare

Results:167uniquepatientsreceivedcarefrom40nursesubjectsover120individualshifts.2,185cultureswereobtainedfromHCPclothing,455frompatients,and2,919frompatients’environments. Themedianunadjustedincreasesincontaminationweresimilaramongscrubtypes.ScrubtypewasnotassociatedwithadecreaseinHCPclothingcontamination.

Conclusion:Antimicrobial-impregnatedscrubsdidnotleadtodecreasedcontaminationofnursesclothing.

AreAntimicrobialCurtainsasCleanasYouThink?IDWEEKAbstract260,2016

SHELASRIAR,MD,etal.MedicalCollegeofWisconsin,Milwaukee,WI,

Background:Weaimedtodeterminethedegreeofbacterialcontaminationonantimicrobialcurtainswithinourmedicalintensivecareunit(ICU).

Results:Wefoundthatoutof20curtains,95%(n=19)showedbacterialgrowth.Outofthe10doorcurtains50%(n=5)showedGram-negativebacilliand100%(n=10)hadGram-positiveorganisms.Outofthe10commodecurtains,10%(n=1)showedGram-negativeorganismsand90%(n=9)hadGram-positiveorganisms

Conclusion:Antimicrobialcurtainsarecontaminatedwithpathogenicorganisms;therefore,theyshouldbethoroughlydisinfected,exchanged,ortotallyforegoneinbetweenpatients.

Thankyou!

Questions?