Which strategy is most cost-effective in preventing the transmission of C. difficile?

As resources become more and more constrained in healthcare facilities around the world, we need to think in terms of both effectiveness, and cost-effectiveness. A new modelling study published in PLoS ONE evaluates the cost-effectiveness of several strategies to prevent the transmission of C. difficile. Probably the key finding of the study is that hand hygiene compliance, environmental decontamination, and empiric isolation and treatment were the most effective interventions.

The model was a simulation of C. difficile transmission, including estimates for the following parameters: interactions between patients and health care workers; room contamination via C. difficile shedding; C. difficile hand carriage and removal via hand hygiene; patient acquisition of C.
difficile via contact with contaminated rooms or health care workers; and patient antimicrobial
use. Six interventions were then tested either individually or as a bundle at three levels of efficacy (base-case (BASE) to reflect typical hospital practice, (2) intervention (INT) to represent implementation of hospital-wide efforts to reduce C. diffiicle transmission, and (3) optimal (OPT)to represent the highest expected results from strong adherence to the interventions), and at three levels of transmission and importation (low, medium, and high).

Bundled interventions were most cost-effective, and hand hygiene compliance, environmental decontamination, and empiric isolation and treatment were most effective as individual interventions.

This study supports most approaches to C. difficile management, which recommend a bundle of interventions including focus on hand and environmental hygiene, and patient isolation.

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Standardising the testing of disinfectant wipes

wipe
There has been quite a bit of discussion lately about the suitability of laboratory testing methods for wipes. This is a crucial issue, and may explain to a large degree the differences in wipe performed when tested in parallel. For example, a study of wipes with sporicidal claims found that few actually demonstrated meaningful sporicidal activity!

A recent study in the Journal of Hospital Infection aims to standardise the testing of disinfectant wipes using an ASTM method. The protocol depends on using a “Wiperator”, which standardises the pressure and motion used to apply the wipe to the inoculated test surfaces. The new test protocol was put through its paces by three laboratories testing the efficacy of five disinfectant wipes against two common pathogens (S. aureus and A. baumannii). Reassuringly, all of the wipes tested achieved a >4-log reduction on the test bacteria within 10s of wiping, and 3/5 wipes tested achieved a >7-log reduction on the test bacteria. However, only one of the wipes tested (based on 0.5% accelerated H2O2) prevented the transfer of bacteria to another surface.

This methodology solves a number of common problems with other methods used to test the efficacy of disinfectant wipes, especially standardising the pressure and wiping motion; the inclusion of a measure of the risk of onward transfer of bacteria to other surfaces is another important inclusion in the protocol. It seems likely that this disinfectant wipe testing standard will quickly become the gold standard method.

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Chlorhexidine daily bathing reduces infections: multicentre study in the US

CHG_bathing_alternative_pack1 An ambitious study involving ICUs in 33 community hospitals in the US over a period over five years evaluated the impact of chlorhexidine (CHG) daily bathing. ICUs in 17 hospitals implemented CHG daily bathing, whereas 16 ICUs did not, and served as controls. The study evaluated any potential changes in a host of infection-related outcomes, including CLABSI, any BSI, VAP, CAUTI, and VRE and MRSA HCAIs.

The ICUs were not randomised to the intervention, but it’s a pretty good sample size so you’d expect any variability to be smoothed out naturally. However, it is worth nothing that 88% of the hospitals that implemented CHG bathing also had an active MRSA screening programme, whereas only 50% of the hospitals that did not implement CHG bathing had an MRSA screening programme. Thus, implementing CHG could be a marker of a more complete infection prevention and control programme, which could confound these findings. Perhaps related to this is the finding that MRSA, VRE, CAUTI, CLABSI, all primary BSI and VAP were all more common in the ICUs that implemented CHG, suggesting that the baseline characteristics of the units that chosen to implement CHG were different to those that did not.

Nonetheless, the results from the time series analysis (which evaluated whether there were changes in the rate of these HCAI-related outcomes) are impressive: CLABSIs were reduced by 59%, primary BSIs by 36%, and VRE CLABSIs by 33% on the units that were using CHG daily bathing. There were no changes in the rate of MRSA-related HCAI metrics.

This study performed in a large number of community hospitals (rather than large academic teaching hospitals) provides real-world data that CHG bathing reduces the rate of important HCAIs. However, it also illustrates that CHG bathing is not a silver bullet and needs for form part of a multifaceted strategy to prevent HCAI on ICUs.

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Transmission routes of the Zika virus

zikaThe Zika virus was first identified in Africa in the 1940s but has recently hit the headlines due to a sharp apparent increase in prevalence in some parts of the world, and a potential link with microcephaly.  The Zika virus is transmitted mainly through mosquito bites, but could there be any infection prevention and control implications? The short answer is no: human-to-human transmission of the Zika virus appears to be rare, although a small number of reports of sexual transmission, horizontal transmission (from mother to baby), and transmission via blood transfusions have been reported.
 
So, it seems that the steps required to prevent the transmission of Zika are similar to those required for malaria. Preventing being bitten by a mosquito in high prevalence areas is the key to prevention. What is not known is what is driving the recent increase in prevalence. But we will watch the emerging story carefully to ensure no other infection prevention and control challenges emerge.

Click on this link to show an interesting and insightful infographic about the Zika Virus: http://www.mphonline.org/zika-virus/  

 

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The physical environment and norovirus containment

noro
As norovirus season gets into full swing, spare a thought for those hospital that still have open plan ‘Nightingale’ style wards. These worked for Florence in a Victorian era, but narrow bed spacing and a lack of single rooms makes the containment of infectious diseases very challenging in these wards.
 
A study just published in the Journal of Infectious Diseases puts some numbers to this risk, finding that the frequency of norovirus outbreaks varied hugely across 6 hospitals in the London area. With 2 or fewer outbreaks reported in 5/6 and a whopping 16 separate outbreaks in one of the hospitals. This hospital had the lowest proportion of single rooms (a miserly 7%) and the tightest bed spacing (2.3m between bed centres), and the authors attribute these structural challenges to the frequent outbreaks in these hospitals.
 
Managing norovirus in these challenging ward environments may require some additional measures. Whilst effective hand and environmental hygiene are the key to controlling the spread of noro, this needs to be complemented with effective isolation of patients. Perhaps more segregated cohorting of patients would be a way to tackle segregation of patients with diarrhoea and vomiting in Nightingale wards? But the real solution to address this issue is to increase the number of single rooms in new hospitals!

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