Infection Control Today

DEC 2018

ICT delivers to infection preventionists & their colleagues in the operating room, sterile processing/central sterile, environmental services & materials management, timely & relevant news, trends & information impacting the profession & the industry

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29 December 2018 ICT found 8.1 percent of patients were colonized and that 22 percent of patients colonized at admission developed C. diff while only 3 percent of non-colonized patients developed CDI. These studies suggest low but consistent levels of patients are colonized with C. diff when entering healthcare facilities. ESBL-Producing bacteria: Cochard (2014) studied ESBL producing Enterobacteriaceae rates in French nursing homes. Surveillance of residents found the colonization rate was 9.9 percent. Fifteen percent of residents had been recently hospitalized and 35.4 percent had recently received antibiotics. Staff compliance with infection prevention protocols were low. Hand hygiene compliance was 25.7 percent, glove use was 45.9 percent, PPE use was 13.3 percent and waste management compliance was 46.7 percent. Homes with the highest compliance rates had the lowest ESBL colonization rates and those with the lowest compliance rates had the highest ESBL carriage rates. Possible Solutions To minimize the risk of environmental contamination by colonized patients, additional practices may be appropriate. • Patient hand hygiene: Hand sanitizer readily available for patients to use prior to meals, entering or leaving their room, after toileting, etc. would be benefcial. The use of disposable alcohol-based hand wipes can reduce the number of organisms on the patient's hands. • Disinfection of surfaces at the point of care: Reducing the bio-burden in the patient care environment can be improved by coaching staff to be actively engaged in keeping the high-touch surfaces of the patient environment clean. All disciplines need to be educated to disinfect the environment before and after certain activities and/or procedures that may contaminate the near-patient environment. This can be accomplished by providing a safe disinfectant at point of care. This can also help ensure that mobile patient care equipment is disinfected between patients. • Decolonization: Some facilities have implemented daily bathing with chlorhexidine gluconate (CHG) for any patient with a "line" (central line or Foley). Patients undergoing certain surgical procedures, or being admitted to an ICU, could also be screened for MRSA and if positive, treated with mupirocin. Pre-op skin cleansing the night before and morning of surgery with CHG may also reduce shedding of potentially pathogenic organisms. Some facilities more broadly decolonize patient nares for all surgical procedures involving implants or if the patient is deemed a high risk. • Cleanin g vali dat io n: Ensuring all surfaces have had contact with c l e a n e r/d i s i nfe c t a nt s w i l l ke e p b i o b u r d e n l o w. R e g u l a r a u d i t s a re re co m m e n d e d by t h e CD C (Guh 2010). Humans continuously shed bacteria into their environment. All people colonized with certain pathogens discussed above can shed bacteria that can potentially cause infections in others. Colonization is an underappreciated source of pathogen dissemination that contributes to widespread environmental contamination as many studies showed. Dissemination of pathogens that result in hand or surface contamination is an important step in ultimately causing a healthcare acquired infection and needs to be studied further. Healthcare facilities should assess current policies and procedures to determine the implications of patient colonization within their facility. Peter Teska is a Diversey infection prevention application expert; Jim Gauthier is a Diversey senior clinical advisor, and Carol Calabrese is a Diversey senior clinical advisor. References: Public Health Agency of Canada (PHAC). Routine practices and additional precautions for preventing the transmission of infection in health care. Ottawa, ON: Her Majesty the Queen in Right of Canada; 2012. Available from: http://publications.gc.ca/ collections/collection_2013/aspc-phac/HP40-83- 2013-eng.pdf Sender R, Fuchs S, Milo R. Revised Estimates for the Number of Human and Bacteria Cells in the Body. PLoS Biol, 2016;14(8):e1002533. doi:10.1371/ journal.pbio.1002533. Kelly CP, et. al. Clostridium diffcile colitis. N Engl J Med, 1994; 330 (4): 257-262. Stephen AM. The microbial contribution to human fecal mass. J Med Microbiol, 1980; 13(1): 45-56. Ray AJ, et al. Nosocomial transmission of vancomycin-resistant enterococci from surfaces. JAMA 2002; 287:1400-1401. Revolinski SL, et. al. Clostridium diffcile exposures, colonization, and the microbiome: implications for prevention. 2018; 39(5): 596-602. Boyce JM, et al. Widespread environmental contamination associated with patients with diarrhea and methicillin-resistant Staphylococcus aureus colonization of the gastrointestinal tract. Infect Cont Hosp Epidemiol, 2007; 28 (10):1142-1147. Knowlton SD, et al. Bioaerosol concentrations generated from toilet fushing in a hospital-based patient care setting. Antimicrob Resist Infect Infect Control, 2018; 7:16. DOI 10.1186/s13756-018-0301-9 Lamont RJ, et. al. Oral microbiology at a glance. 2010, Wiley -Blackwell. West Sussex UK. American Academy of Dermatology Association, "How skin grows", 2018. Retrieved from: https:// www.aad.org/public/kids/skin/how-skin-grows. Meadow JF, Altrichter AE, Bateman AC, et al. "Humans differ in their personal microbial cloud." Souza V, ed. PeerJ. 2015; 3:e1258. doi:10.7717/ peerj.1258. Cao J, et. al. Multi-drug resistant organisms on patients' hands: A missed opportunity. JAMA Intern Med, 2016; 176 (5): 705-706. Patel PK, et. al. "Patient hand colonization with MRDOs is associated with environmental contamination in post-acute care. Infect Cont Hosp Epidemiol, 2017; 38 (9): 1110-1113. McKinnell JA, et. al. Quantifying the impact of extranasal testing of body sites for Methicillin- Resistant Staphylococcus aureus colonization at the time of hospital or intensive care unit admission. Infect Cont Hosp Epidemiol, 2013; 34 (2): 161-170. Munro N, et al. Ventilator-associated pneumonia bundle. AACN Adv Crit Care, 2014; 25(2): 163-175 Mayer RA, et. al. Role of fecal incontinence in contamination of the environment with vancomycin-resistant Enterococci. Am J Infect Cont, 2003; 31 (4): 221-225. Lee AS, et. al. Defning the role of the environment in the emergence and persistence of vanA Vancomycin-Resistant Enterococcus (VRE) in an intensive care unit: A molecular epidemiological study. Infect Cont Hosp Epidemiol, 2018; 39(6): 668-675. Thom KA, et. al. "Environmental contamination because of multi-drug resistant Acinetobacter baumannii surrounding colonized or infected patients". Am J Infect Cont, 2011; 39 (9): 711-715. Crew PE, et. al. "Correlation between hospital-level antibiotic consumption and incident health care facility-onset Clostridium diffcile infection", Am J Infect Cont, 2018; 46: 270-275. Freedberg DE, et. al. "Receipt of antibiotics in hospitalized patients and risk for Clostridium diffcile infection in subsequent patients who occupy the same bed". JAMA Intern Med, 2016; 176 (12): 1801-1808. Best EL, et. al. "The potential for airborne dispersal of Clostridium diffcile from symptomatic patients". Clin Infect Dis, 2010; 50 (1): 1450-1457. Yui S, et al. "Identifcation of Clostridium diffcile reservoirs in the patient environment and effcacy of aerial hydrogen peroxide decontamination". Infect Cont Hosp Epidemiol, 2017; 38 (12):1487-1492. Sethi AK, et. al. "Persistence of skin contamination and environmental shedding of Clostridium diffcile during and after treatment of C. diffcile Infection", Infect Cont Hosp Epidemiol, 2010; 31 (1): 21-27. Riggs MM, et. al. "Asymptomatic carriers are a potential source for transmission of epidemic and nonepidemic Clostridium diffcile strains among long-term care facility residents", Clin Infect Dis, 2007; 45: 992-998. Cochard H, et. al. "Extended-Spectrum ß-lactamase– producing Enterobacteriaceae in French nursing homes: an association between high carriage rate among residents, environmental contamination, poor conformity with good hygiene practice, and putative resident-to-resident transmission", Infect Cont Hosp Epidemiol, 2014; 35 (4): 384-389. Guh A, et al. Options for evaluating environmental cleaning". Centers for Disease Control and Prevention 2010. Available at: www.cdc.gov/hai/pdfs/toolkits/ Environ-Cleaning-Eval-Toolkit12-2-2010.pdf

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