It’s been a month or two since the 2018 Infection Prevention Society Conference in Glasgow, Scotland. So, we thought it would be a good time to look back and remind ourselves of some of the highlights from our point of view. You can access all of the IPS abstracts here.
– Andreas Voss gave a fabulous lecture on a water free ICU. Whilst this concept is very challenging, and feels pretty uncomfortable, the logic is clear. The risk of bacterial contamination from water, especially related to Pseudomonas, is commonplace and difficult to control. By using alcohol gels for hand hygiene most of the time, and hand wipes when hand washing with soap and water would usually be performed (e.g. when hands are visibly soiled), and sterile water for other patient care activities, tap water can be removed from the clinical environment. Evidence from a couple of studies shows that this intervention reduces the rate of antibiotic resistant Gram-negative bacteria in the critical care setting.
– Related to this, research by the University of West London (including our very own Clinical Director, Martin Kiernan) found that hand hygiene performed using antimicrobial hand wipes is just as effective as hand washing using soap and water (abstract #123).
– More work from the University of West London investigated the frequency of patient hand hygiene (abstract #130). In observational evaluations of patient opportunities for hand hygiene, patients had access to hand hygiene facilities in only 31% of 303 opportunities. Antimicrobial hand wipes would help to at least provide patients with the facilities to perform hand hygiene.
– Work from Cardiff University shows that biofilms are incredibly common in healthcare settings, with 95% of 60 items collected from three hospitals in the UK harbouring dry surface biofilm (abstract #96).
– Research from Guy’s and St. Thomas’ in London reports on the introduction of Clinell’s Violet UV-C room decontamination system into an acute admissions ward (abstract #77). In this setting, turnaround time is paramount and there usually isn’t time for hydrogen peroxide vapour room decontamination. UV-C was deployed a staggering 3980 times over the course of a year (more than 10 times per day), with turnaround time for UV-C at 1 hour (including room cleaning we presume) compared with 3 hours for hydrogen peroxide vapour. This reinforces that UV-C has an important role to play in automated room decontamination, mainly when C. difficile spores are not the target organism.
– And finally… we launched Rediroom! This is designed to provide instant patient isolation in hospitals. We were delighted that Rediroom won the vote as the best product in the ‘Pitch in 5’ section of the inaugural IPS Show!
Thanks to the conference organisers for another stellar conference!
The 2018 English Surveillance Programme for Antimicrobial Utilisation and Resistance (ESPAUR) report has just been released by Public Health England (PHE) and, as with most reports the results show a mixed picture. The good news is that total antibiotic consumption has fallen by 6% over the past four years and is [now] at the lowest level since 2011. The majority of antibiotics continue to be prescribed in primary care (72%), with hospital inpatients making up 12% of the total. Further progress is possible, as PHE estimate that 20% of antibiotics are being prescribed inappropriately, with the vast majority of this being in primary care.
These encouraging figures however are tempered by the not-so-good news that gram-negative bacteria with a detected carbapenemase have increased year-on-year to around 3,000 cases in 2017. The figures show that there has been a 35% increase from 2013 to 2017 in the detection of carbapenemase-producing bacteria. This increasing burden of infections that are extremely difficult to treat means that prevention of infections becomes even more critical. Prevention is coming to the fore, with the report stating that “It is clear that more work needs to be done to both prevent serious infections and reduce the pressure of antibiotic use for the selection of antibiotic-resistant bacteria”. It is pleasing to see that the number one future action for ESPAUR will be to emphasise the importance of infection prevention and control with the objective of reducing the numbers of antibiotic-resistant infections. In the coming years as resistance continues to increase, prevention of infections will not only help reduce morbidity and mortality, it will mean that resistant organisms are not selected out by widespread use of the decreasing list of effective antibiotics that we still have.
A Canadian study reports the findings of a prospective survey of bacterial contamination of privacy curtains in hospitals. The curtains became contaminated with antibiotic resistant bacteria within weeks of being introduced into the clinical environment. The calls into question the management of privacy curtains in the healthcare setting.
Previous studies have found that privacy curtains can be contaminated with antibiotic-resistant bacteria when sampled at a point in time. The unique aspect of this study was that 8 newly hung test curtains in a ward were sampled regularly over 21 days, and compared to control curtains hung in non-clinical areas. This allows us to understand how rapidly the curtains became contaminated. Within 3 days, the curtains in the clinical areas were showing increased contamination compared with the control curtains, and by day 14, 5 of the 8 curtains were contaminated with MRSA.
Protocols for managing privacy curtains vary considerably from hospital to hospital. Some are changed regularly, others, once in a blue moon! Whilst it may be possible to partially disinfect curtains whilst they are hung in a clinical setting (e.g. by using a chemical spray), this will be challenging. Therefore, linen privacy curtains should be changed frequently, and immediately if visibly contaminated with blood or other body fluid and after moving a patient known to be infected or colonised with antibiotic resistant bacteria or other HCAI pathogens such as C. difficile or norovirus. Also, it’s worth considering other patient privacy options (such as non-linen curtains, disposable curtains, screens, or temporary single rooms).
A study from Singapore has highlighted extensive environmental contamination with carbapenem-resistant Acinetobacter baumannii in the ICU. This reinforces the need for enhanced environmental measures to reduce the transmission of carbapenem-resistant Acinetobacter baumannii in the ICU setting.
Carbapenem-resistant Acinetobacter baumannii is in many ways a scary organism: it’s highly resistant to antibiotics with few therapeutic options left in some cases, seems to spread readily in ICUs and burns units, and has an extraordinary ability to survive in the dry environment. One study reported that A. baumannii can survive for more than a year on dry surfaces – and that’s without a water or nutrient source!
During an outbreak of carbapenem-resistant Acinetobacter baumannii in an ICU in Singapore, the team performed a point prevalence survey of patient colonisation / infection and environmental contamination with carbapenem-resistant Acinetobacter baumannii. Environmental contamination was identified in 28% (5/18) of the rooms on the ICU. Whole genome sequencing found that environmental isolates were closely related to the patient in the room, but differed between rooms. This suggests that the environmental isolates originated from the patient in the room.
These findings reinforce the need for enhanced disinfection when dealing with carbapenem-resistant Acinetobacter baumannii, especially at the time of patient discharge. This will reduce the risk that contaminated surfaces become a reservoir for room-to-room transmission of carbapenem-resistant Acinetobacter baumannii.
A useful review published recently in an orthopaedic surgery journal (by Katarincic et al.) covers the various interventions that are often introduced to reduce the risk of surgical site infection (SSI). The evidence for some interventions is stronger than others, but there’s much we can do throughout the patient journey to reduce the risk of SSI, from pre-operative bathing, through antisepsis of the incision site, to effective post-operative wound care.
The evidence for the prevention of SSIs is reviewed thoroughly in the NICE guidelines on SSI prevention, which cover pre-operative, intra-operative, and post-operative measures. However, these guidelines were published in 2008, so a whole decade of SSI prevention research is missing! The review by Katarincic et al. is more pragmatic, spending more time on some of the more contentious issues. For example, whilst antisepsis of the incision site using either chlorhexidine or povidone-iodine is recommended, the NICE SSI guidelines are lukewarm on whether or not to implement chlorhexidine body washing prior to surgery, recommending bathing or showing using soap on the day before, or on the day of, surgery. The authors of the review by Katarincic et al. come to a different conclusion following their review of the evidence on chlorhexidine bathing before surgery: ‘Use chlorhexidine wipes both the night before and the morning of surgery, provide patients with written instructions, and institute a web-based alert for maximum compliance.’
Part of the reason for this difference is that much evidence around the use of chlorhexidine bathing has been published since the NICE recommendations were published. Also though, the review by Katarincic et al. is careful to consider compliance with the chlorhexidine bathing protocol when interpreting the evidence. A number of ‘negative’ studies, concluding that chlorhexidine bathing does not reduce SSIs have poor compliance with chlorhexidine bathing. For example, a prospective cohort study by Johnson et al. found that the infection rate in non-compliant patients in the chlorhexidine bathing arm of the study was 1.6% compared with 0% in the compliant patients in the chlorhexidine bathing arm of the study. And we know from other studies that the use of wipes (vs. solution) can help improve compliance with chlorhexidine bathing.
SSI prevention measures need to be supported by effective guidelines, which take into account compliance with interventions, when considering recommendations. To tackle SSI effectively requires the implementation of prevention measures throughout the patient journey. Based on the latest evidence, bathing with chlorhexidine before surgery makes sense as part of an SSI prevention programme.