A French study has found that weekly use of disinfectants by nurses is associated with developing chronic pulmonary obstructive disease (COPD). The study supports urgent reconsideration of the widespread use of liquid disinfectants in favour of safer alternatives, including
The large longitudinal study followed 55, 185 US nurses from 2009-2017, and evaluated risk factors for developing COPD. A total of 663 (1%) of nurses developed COPD during the study. Weekly exposure to disinfectants for surface disinfection was a significant risk factor for developing COPD (odds ratio 1.2), even after adjusting for other factors that may cause COPD (such as smoking). Also, exposure to specific disinfectants was a risk factor for COPD (including chlorine, aldehydes, and quaternary ammonium compounds). Unsurprisingly, the study has prompted some coverage in mainstream news outlets, like the Metro, Independent, and Guardian.
Other studies have found that some disinfectants are associated with developing asthma, but this is the largest dataset to link the use of disinfectants with COPD. It is important to note that the study focussed on nurses, and other staff groups (especially cleaners) are likely to be at even greater risk of disinfectant-associated COPD. This study argues strongly for rapidly phasing out the use of liquid disinfectants and replacing them with alternative approaches, including disinfectant-impregnated wipes.
IVupdate have published an interview with Martin Kiernan (our very own clinical director) by Andrew Jackson of IVTeam.com, which is well worth a listen. The interview covers Martin's career (listen out for the words of wisdom from used car sales...), proudest moments, views on patient safety, and the importance of bundle implementation.
The focus of the interview is around bundles to reduce the risk of vascular line-associated infection. Chlorhexidine bathing is gaining increasing acceptance of as a key component of vascular-line associated infection prevention bundles, but it is only part of the picture. Whilst it could be said that the very existence of bundles represents an evidence gap, because we are often unclear which elements of the bundle are effective, one thing is certain: a bundle will not be effective if it's not implemented correctly. And the way to ensure a bundle is implemented effectively? Education, education, education! Top down approaches do not work; front-line staff need to understand the importance of the issue, and believe in the bundle for it to be implemented in the busy healthcare setting.
If we get the implementation of bundles to prevent vascular line-associated infection right, we should begin to see reductions in line-associated infections due to MSSA and some contribution to the ambition to reduce E. coli and other Gram-negative BSIs.
A Turkish study has found a surprisingly high rate of antiseptic resistance gene carriage in clinical isolates of staphylococci (71% of 69 isolates carried either qacA/B or smr, which have been associated with reduced susceptibility to chlorhexidine). This study highlights the potential for bacteria to eventually develop reduced susceptibility or resistance to whatever is thrown their way!
The study team searched for various antiseptic resistance genes in a collection of 69 Staphylococcus species isolates (a mixture of MRSA, MSSA, and methicillin-resistant and - susceptible coagulase-negative staphylococci (CoNS)) and 69 Enterococcus species. More than 50% of the S. aureus isolates and 85% of the CoNS isolates harboured one or other gene that has been linked with antiseptic resistance (various qac genes, and smr). Furthermore, laboratory testing showed that isolates carrying the resistance genes exhibited lower levels of susceptibility to chlorhexidine, which has been reported elsewhere. The situation was different in Enterococcus species, where none were found to carry these antiseptic resistance genes. However, laboratory testing did show that vancomycin-resistant enterococci (VRE) were less susceptible to antiseptics than vancomycin-susceptible enterococci. This suggest that there may be some link between the mechanism of reduced susceptibility to vancomycin and chlorohexidine, which makes sense because changes in cell wall synthesis are essential to both.
As in other studies, the level of reduced antiseptic susceptibility identified in the laboratory in this study was orders of magnitude lower than the in-use concentration of chlorhexidine that is applied to patients skin. However, it does suggest that, over time, reduced susceptibility to chlorhexidine is likely to become more of a clinical challenge.