An impressive randomised multi-centre study in Japan has evaluated the efficacy of 0.5 and 1% alcohol/chlorhexidine with 10% povidone-iodine in preventing colonisation of vascular catheters. The study concluded that chlorhexidine at either concentration is superior to povidone-iodine in preventing the colonisation of vascular catheters.
The study was performed in 16 Japanese intensive care units. The 796 central venous or arterial catheters included in the final analysis were randomised to 0.5% and 1% alcohol/chlorhexidine with 10% povidone-iodine during insertion and dressing changes. Catheter-tip colonisation was 3.7 events per 1000 catheter-days in the 0.5% chlorhexidine group, 3.8 in the 1% chlorhexidine group, and 10.5 in the povidone-iodine group. The rate of catheter-tip colonisation was statistically significantly lower in both chlorhexidine groups compared with the povidone-iodine group.
It’s important to note a couple of limitations in this study. Firstly, the authors compared chlorhexidine in alcohol with a povidone-iodine solution. So it isn’t possible to disentangle the effect of alcohol from chlorhexidine using this design. Secondly, although the authors tested two concentrations of chlorhexidine (0.5% and 1%), both are lower than would usually be used in clinical settings in most parts of the world (2%). Thirdly, there was no impact on the rate of catheter-related bloodstream infections between the two groups, although this may be a factor of sample size, because the primary outcome, for which the study was powered, was catheter tip colonisation.
Despite these limitations, the findings of this large randomised trial are compelling, finding that vascular line-tip colonisation is less than half as likely when chlorhexidine is used during insertion and ongoing line care compared with povidone-iodine. This reinforces that chlorhexidine is a better choice than povidone-iodine for skin decontamination during line insertion and ongoing line care in the ICU setting.
A fascinating new study in AJIC suggests that adding a disinfectant to the toilet bowl before flushing results in a significant reduction in viral contamination of a bathroom. Does this mean we should disinfect the loo before flushing it?
The study used MS2 coliphage as a proxy marker of pathogenic virus contamination. The degree of surface contamination of the bathroom was assessed with and without adding the phage to the toilet bowl (at a high concentration of 10^12) before flushing. The bathroom was heavily contaminated with the phage when it was added to the toilet bowl; surfaces were contaminated up to a concentration of 10^6 per 100cm2. Then, the experiments were repeated but this time disinfectants were added to the bowl before flushing: 5-10% hypochlorite, 0.5-2% hydrogen peroxide, QAC, or 0.23% peracetic acid. Perhaps surprisingly, the hypochlorite had limited impact on the concentration of phage in the toilet bowl until a contact time of 30 minutes, whereas both QAC and peracetic acid resulted in a ~2-log reduction with only a 1 minute contact time. The hydrogen peroxide made a limited impact on the concentration of phage at any concentration or contact time.
So does this mean we should disinfect the toilet bowl before flushing? The major problem with this is that the toilet bowl will be full of bodily fluids and organic matter (well, it’s what the toilet is for), so there’s a big risk that any attempt to disinfect the toilet bowl immediately before flushing are unlikely to reduce contamination of the bathroom. The author did attempt to simulate waste in the bowl using a microbiological culture broth – but I suspect the real thing would be a tougher challenge! However, this study does illustrate the risk of contaminating the bathroom with viral aerosol through toilet flushing, and argues for regular (perhaps more regular) disinfection of the toilet bowl!
2017 has been quite a year. We’d like to take the opportunity to thank all of our customers, suppliers, and readers for your contributions, and to highlight a few of our favorite posts this year.
We hope that you have enjoyed reading our blog as much as we’ve enjoyed writing it. Here’s to a restful Christmas and a happy 2018!
A useful summary of current evidence highlights what healthcare workers should know about environmental contamination in hospitals. Whilst the focus of the article in the ICU, the principles are the same for healthcare workers in other settings too. Bacteria contaminate the inanimate environment; this contributes to patient acquisition of pathogens; biofilms play an important but uncertain role; and improved disinfection methods are now warranted.
Key pathogens are shed into the hospital environment. This included MRSA, VRE, C. difficile spores, resistant Gram-negative bacteria (especially Acinetobacter baumannii), and other microbes including fungi and viruses. If not actively killed or removed, they can survive for months and months (or decades in the case of spores). Patients with symptoms tend to shed more than patients who are colonised only, but even asymptomatic carriers shed into the hospital environment. The environmental sites that are closest to patients tend to be more heavily contaminated; and this can result in the acquisition of pathogens on the hands of healthcare workers.
For many years, the scientific community questioned whether all this environmental contamination was cause or effect of patient infection and colonisation with these hospital pathogens. The most powerful evidence that environmental contamination is a cause of HCAI comes from the epidemiological findings that patients admitted to rooms previously occupied by patients with a hospital pathogen are roughly twice as likely to acquire these pathogens. Furthermore, improving the effectiveness of hospital cleaning and disinfection mitigates this increased risk, reinforcing that environmental contamination has important clinical impact.
A few years ago, biofilms were first identified on dry hospital surfaces. This was a surprise: previously biofilms had been associated with the wet surfaces in aqueous environments (e.g. ships hulls and teeth)! This finding has important implications: biofilms could explain the extraordinarily long survival time of non-spore forming bacteria on dry hospital surfaces, and why they are so difficult to kill. Bacteria embedded in biofilms can be hundreds or even thousands of times less susceptible to disinfectants.
All of this argues for improved disinfection. There’s a lot that we can do to improve the efficacy of existing materials and methods. For example, using fluorescent markers can help to highlight areas that are not being cleaned effectively. Pre-impregnated disinfectant wipes are a useful innovation, making cleaning faster, more convenient, safer for staff, and reducing the risk of incorrectly formulated disinfectants being used. And automated room disinfection systems (such as those based on hydrogen peroxide and UVC) have been shown to achieve higher levels of surface hygiene than conventional methods, which translates into improved patient outcomes.
Sporicidal disinfectant wipes are being used increasingly for tackling surfaces contaminated with C. difficile spores in hospitals. A wide range of ‘sporicidal’ wipes are coming onto the market. However, concerning published data shows that some wipes marketed as being ‘sporicidal’ do not have meaningful activity against spores when tested under controlled laboratory conditions. This blog outlines three key questions that you should be asking when a company comes to you with a ‘sporicidal’ wipe: is it plausible that the chemicals in the wipe will have sporicidal activity? Does the laboratory data provided by the manufacturer support their claims? Were the tests performed in a reputable, accredited laboratory? If the answer to any of these questions is no, then your wipe probably isn’t sporicidal and you should look for an alternative!
There is rapidly accumulating evidence that disinfectant wipes out-perform ‘bucket’ methods for disinfection. They are more convenient, assure the correct concentration of disinfectant, are safer for users, and make it easier to achieve an appropriate contact time. A particular challenge in hospitals is disinfecting surfaces that may be contaminated with C. difficile spores, or clinical areas that have been used to treat diarrhoea and vomiting where a pathogen has not been identified. Wipes with sporicidal activity can help to reduce the transmission of C. difficile in hospitals. So disinfectant providers have responded by developing a whole range of sporicidal wipes. The problem is that some of these wipes have very limited or no sporicidal activity. This blog aims to help users in negotiating a complex marketplace of sporicidal wipes using three simple questions:
- Is it plausible that the chemicals in the wipe will have sporicidal activity?
We know from centuries of research that some chemicals, notably oxidising agents (for example peracetic acid, hydrogen peroxide and hypochlorites) have sporicidal properties when in the right formulation and at the right concentration. However, other chemicals do not have sporicidal activity, notably quaternary ammonium compounds even when combined with triamines, even though suboptimal testing methods, particularly when neutralising the agents may provide the apprearance of sporicidal activity. GAMA produce such a wipe and would never claim sporicidal activity.
- Does the laboratory data provided by the manufacturer support their claims?
There is no current European standard test for sporicidal efficacy in the healthcare sector. In lieu of a more appropriate test, healthcare disinfectant manufacturers often use EN 13704, but a Joint Working Party from the Healthcare Infection Society (HIS) and the Advisory Committee on Antimicrobial Resistance and Healthcare Associated Infections (ARHAI) of the Department of Health England recommended that it requires significant modification to evaluate sporicidal activity in conditions reflective of a healthcare environment. Therefore, passing laboratory tests based on these Working Party guidelines should be regarded as the minimum standard for a sporicidal wipes to be used in healthcare settings.
- Were the tests performed in a reputable, accredited laboratory? Even if the laboratory data tick all the right boxes and the wipe seems to exhibit sporicidal activity, it’s important to ensure that there is assurance that these data are robust and that the testing laboratory is accredited. Laboratories that state that they are ‘working towards’ ISO and UKAC accreditation are therefore not accredited. This is not to say that non-accredited labs are always inferior or inaccurate, as many well-respected University and Hospital research labs are not accredited. It’s just that laboratory accreditation is designed to ensure that standard tests are performed in a standardised way so that everybody can rely on the results.
GAMA has produced a Sporicidal Wipe based on peracetic acid. Peracetic acid has long been known to have sporicidal properties, the wipe has been tested using appropriate methods in independent, accredited laboratories and also in respected university laboratories. If you’d like to have some more detailed information on this issue, or you’d like to speak with an expert at GAMA (or we can put you onto an independent expert), please get in touch.