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.
There is accumulating evidence that daily bathing using chlorhexidine wipes prevents the transmission of MDROs. Most of the evidence to date has been about reducing Gram-positive bacterial pathogens (such as MRSA and VRE). So a study including Gram-negative bacterial pathogens (such as Klebsiella pneumoniae and E. coli) is welcome! A recent Spanish study shows that daily bathing with chlorhexidine is effective in reducing colonisation with MDROs.
The prospective intervention study was performed in a 24 bed mixed-speciality ICU in a Spanish hospital over two years. Daily bathing using Clinell Wash Cloths (2% chlorhexidine gluconate, CHG) was implemented after 11 months, to provide 12 months pre, and 11 months post intervention data. Mechanically ventilated patients and patients known to be colonised with MDROs were bathed daily using CHG. Patients admitted from other hospital wards or transferred from other hospitals were screened for MDROs on admission, and all patients were screened once per week for MDROs (or twice per week for mechanically ventilated patients).
Around 25% of patients admitted to the unit during the intervention were bathed daily using CHG. The key finding is the stark change in the incidence of colonisation with MDROs associated with the introduction of CHG (see Figure below). Importantly, there was no significant change in antimicrobial consumption on the ICU during this period. Interestingly, the authors report that no significant reduction in the incidence of MDRO colonisation was found in a surgical ICU during the same period that was not using CHG bathing, which provides a useful ‘natural’ control group for these findings. Whilst there was no significant reduction in infections in total or due to MDROs, the study was not powered adequately to detect a reduction in these outcomes. It’s a fairly safe assumption that if you reduce the number of patients who are colonised with MDROs, this will have a knock-on effect of reducing the number of infections with MDROs!
The study setting had a high prevalence of MDRO colonisation, with approximately 20% of patients colonised with one MDRO or another. Whilst this is a single centre study performed over a relatively short period of time, it provides further evidence that daily CHG bathing reduces the transmission of MDROs including antibiotic-resistant Gram-negative bacteria.
Following on from last week’s blog about the functional characteristics
of the RediRoom (a temporary isolation room designed for single patient use), this week’s blog reviews a second study that evaluates the infection prevention and control characteristics and potential benefits of the RediRoom.
Whether to favour single rooms or multi-occupany bays is a balance. On the one hand, single rooms provide more privacy, less noise, and better containment of pathogens. On the other hand though, multi-occupancy bays provide more social interaction, reduced cost in terms of staffing levels, and patients who fall or deteriorate will be spotted more quickly. Perhaps as a result of this balancing act, patient opinion is divided on whether single rooms or mutli-occupancy bays are better. Most modern hospitals have decided to provide a mixture of single rooms and multi-occupancy bays, to offer flexibility to staff in finding the best accommodation for patients. The RediRoom occupies the middle ground: providing many of the benefits of single occupancy rooms (in terms of more privacy, less noise, and better containment of pathogens) and multi-occupancy bays (patient visibility, and reduced cost in terms of staffing).
The RediRoom was installed in a simulated clinical environment, and its function was assessed from an IPC viewpoint against key standards or guidelines (Australasian Health Facility Guidelines and the Department of Health (NHS) Infection Control in the Built Environment), and the ease of assembly and dismantling, and the ability to clean the RediRoom as judged by the removal of fluorescent markers were evaluated. The RediRoom was found to be fully compliant with 17/19 relevant guidelines or standards, and partially compliant with the other two. The two guidelines rated as partially compliant were the storage and use of personal protective equipment, and the provision of additional storage capacity. Another limitation was the lack of a sink for hand hygiene inside the RediRoom, but there is provision for alcohol gel to be situated both inside and outside the RediRoom. The review of assembly and dismantling of the RediRoom identified limited infection control risk. Impressively, the RediRoom was installed in less than 5 minutes! Finally, the cleaning assessment found that the UV fluorescent markers were fully removed from 23 (96%) of the 24 surfaces marked, and partially removed from the other surface. Whilst this cleaning assessment was not performed in the business of clinical practice, it demonstrates that the RediRoom does not present a barrier to cleaning in principle.
The RediRoom performed well when compared against standards and guidelines for a safe healthcare environment, it did not introduce infection control risks during assembly and dismantling, and was designed in a way that should not be a barrier to cleaning. Clearly, further assessments of the RediRoom in clinical practice are required, but it is poised to deliver IPC benefits!