Tag Archives: Cdiff environmental safety

Case Study Investigators Utilized a Bleach Product That Showed Significant Reduction In Contamination

 

 

By:Saskia v. Popescu Saskia v. Popescu, MPH, MA, CIC, is a hospital epidemiologist and infection preventionist with Phoenix Children’s Hospital. During her work as an infection preventionist she performed surveillance for infectious diseases, preparedness, and Ebola-response practices. She is currently a PhD candidate in Biodefense at George Mason University where her research focuses on the role of infection prevention in facilitating global health security efforts. She is certified in Infection Control.

Clostridium difficile (C diff) infections are pretty much a nightmare for infection preventionists. They cause horrible illness in patients and the spore is environmentally hardy, which makes disinfection efforts extremely challenging. The US Centers for Disease Control and Prevention (CDC) estimates that, in the United States, half a million cases of C diff occur every year, and roughly 15,000 people die due to the infection. As a result of the severity of these infections and the challenges for infection control, it’s not surprising that surveillance and reporting is required not only by many state laws, but also reimbursement regulations through the Centers for Medicare and Medicaid Services (CMS). All of these factors make C diff prevention a major focus for hospitals.

Since the C diff spores are so environmental hardy, cleaning and disinfecting is particularly challenging. Bleach products are required to combat the spread of the spores on surfaces and fomites while soap and water is required for hand hygiene instead of alcohol-based hand sanitizer. These cleaning requirements pose problems though; sometimes bleach can be corrosive on medical equipment if manufacturer guidelines aren’t followed. Moreover, C diff can easily spread if patients aren’t isolated appropriately, if the room isn’t cleaned effectively, if hygiene failures occur, etc. One of the tough aspects of infection control in the face of C diff is the role of the asymptomatic carrier (i.e. the patient who is not experiencing symptoms that would trigger testing and isolation precautions but has the capacity to shed the spores).

A new study in the American Journal of Infection Control sought to address this often undervalued vector for transmission and the true burden of C diff spores in rooms after they were cleaned post-discharge and did not house a C diff patient. Investigators used the Louis Stokes Cleveland Veterans Affairs Medical Center, a 215-bed acute care facility, to test whether cleaning with bleach products in non-C diff rooms would impact contamination.

Prior to their study, daily and discharge cleaning for C diff rooms utilized bleach wipes, while a quaternary ammonium disinfectant was used for non-C diff rooms. Investigators used Clorox Healthcare Fuzion Cleaner, which is a bleach spray that has less corrosive effects. Although cleaning efficacy had previously been measured with fluorescent markets, the team relied on cultures to identify both C diff spore and methicillin-resistant Staphylococcus aureus (MRSA) contamination for this study.

Non-C diff rooms were tested for 3 weeks before the switch to the bleach-spray disinfectant and then, after the swap, tested again after cleaning of the room but before admission of a new patient. Ultimately, the goal was to determine how many rooms had environmental contamination with C diff spores before and after the change in disinfectants.

There were 51 non-C diff rooms tested after the post-discharge cleaning and prior to the switch to the bleach spray, and 39 non-C diff rooms were cultured after switching to the bleach product. The results were pretty astounding and definitely make the case for using bleach-based products in all post-discharge rooms.

Prior to switching products, 24% (12/51) of the rooms had contamination of at least one site (room and/or bathroom) and 10% had MRSA contamination. When cleaning practices were switched to use the bleach spray, the rate of contamination severely dropped—2 of 39 rooms. This trend was statistically significant and also seen in the MRSA contamination.

In this case, the investigators found that by using the bleach-based spray for the post-discharge cleaning of a non-C diff patient’s room, they reduced the contamination from 24% to 5%.

Although the study is limited to a single hospital, it encourages further investigation into general C diff contamination throughout hospitals and whether bleach-based cleaning should be performed upon all discharges, regardless of patient diagnosis with C diff infections.

As C diff continues to grow as a public health and health care concern, the role of environmental contamination will only become more critical. This study sheds light on a new cleaning strategy for hospital-wide disinfecting efforts to reduce microbial burden and C diff contamination. 

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Highlights Of the Latest Advances In the Battle Against the Deadly Pathogen – Dale Gerding, MD

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In September, researchers, health care workers, and industry and patient advocates convened for the 4th Annual International Raising C. diff Awareness Conference and Health Expo in Atlanta.

Clifford McDonald, MD, Associate Director for Science in the Division of Healthcare Quality Promotion at the Centers for Disease Control and Prevention (CDC), chaired the conference. In his role at the CDC, McDonald’s at the forefront of efforts to prevent and treat the infection – one the CDC has declared among the most urgent drug-resistant threats that we currently face.

“It’s my firm belief that we are on the threshold of a new era in better diagnosis, treatment, and prevention approaches. At the CDC, we deal with statistics, but there are faces behind those numbers. At the heart of every infection is a patient who deserves our competence, our empathy, and our passion,” said McDonald.

One of those faces, Roy Poole, is a volunteer patient advocate for the  C Diff Foundation. After retiring from a career in the Air Force, Poole led a healthy, active lifestyle as an avid outdoors-man in Colorado before antibiotics prescribed for a routine dental procedure set the stage for CDI. In the medical community, his symptoms were met with disbelief and inappropriate treatment.

“Three weeks after leaving the hospital, I walked into my (previous) primary care physician, and asked for an order to have a stool sample taken to determine if Toxins A or B were present. His response was, ‘Are you still having problems with that?’ Clearly, there is a need for more education about C. diff among physicians,” said Poole.

CDI is a formidable opponent. However, with the newly focused attention on discovering ways to disable the bacteria and cohesive public health approaches aimed at prevention, presenters from government, academia and industry offered five key reasons we can win the battle against C. diff:

Antibiotic stewardship efforts are gaining a foothold.
Statistics present a chilling picture: 453,000 new cases and an estimated 30,000 deaths each year. It’s likely that those numbers grossly underestimate the true impact of CDI, since it’s what we know from death certificate reporting.

However, we are seeing that rates may have peaked after a long plateau. Mark Wilcox, MD, Head of Microbiology at Leeds Teaching Hospital, Professor of Medical Microbiology at University of Leeds, and the lead on Clostridium difficile for Public Health England in the United Kingdom, has demonstrated a 70% reduction in cases in England in just 7 years. This was after a concerted effort that Wilcox spearheaded surrounding antibiotic stewardship, specifically addressing a reduction in unnecessary prescribing of fluoroquinolones and cephalosporin antibiotics.

Commonly prescribed antibiotics disrupt the protective microbiota (the normal bacteria of the gut) and leave it vulnerable for C. diff colonization. “There was a concerted effort that went beyond lip service and truly embraced the principles of improved surveillance, more accurate diagnostics, enhanced infection prevention measures to use antibiotics more wisely and to limit transmission and careful treatment,” said Wilcox.

High rates of CDI are always associated with the use of certain antibiotics: clindamycin, cephalosporin, and fluoroquinolones. Research has shown that lower respiratory tract infections and urinary tract infections account for more than 50% of all in-patient antibiotics use. But are these really necessary?

“We know that antibiotics are overused and misused across every healthcare setting. At least 30% of antibiotic prescriptions are unnecessary – and this equates to 47 million unnecessary antibiotic prescriptions per year written in doctors’ offices, hospital outpatient departments, and emergency departments. We have a lot of work to do, and CDC is actively working to reduce unnecessary antibiotic use,” said Arjun Srinivasan, MD at the CDC. “Stopping unnecessary antibiotics is the single most effective thing we can do to curb C. diff infections in the United States. This is something that we can do today.”

Srinivasan acknowledged that telling patients that they can’t have a prescription for an antibiotic might result in some pushback. “Patient satisfaction scores are a very real concern. When someone is sick and takes a day off work, they’re not leaving without a prescription – especially when the last provider wrote one for their same symptoms,” he said. “But this is a new day, and it’s up to the physician to educate their patients and stay strong.”

Hospitalists have access to accurate, inexpensive and quick diagnostic tests that can lead to targeted, effective treatment. This can arm the treating physician and patient with information that can put patients on a path to recovery without feeling like they are being dismissed.

Emerging guidance reflects important advances in research and development.

Most recently published in 2010, the Society for Healthcare Epidemiology of America (SHEA) and Infectious Diseases Society of America (IDSA) Clinical Practice Guidelines for C. diff are currently under review. This is critical because of the number of physicians still treating with metronidazole first, despite the fact that the largest randomized controlled clinical trial has shown that vancomycin is more effective.

“Since 2010, the landscape has changed dramatically,” said Stuart B. Johnson, MD, Professor, Department of Medicine, Loyola University, and Researcher at the Hines VA Hospital in Chicago.

“The past few years have ushered in a new age of understanding how and where C. diff colonizes, and the damaging toxins A and B that it produces.”

Considering that 25-30% of patients experience a CDI recurrence, it’s evident that metronidazole unnecessarily contributes to the failed treatment outcomes for patients. Metronidazole is less expensive, but has more side effects than oral vancomycin and is less effective in treating CDI.

Johnson provided an overview of the dramatic advances this space has seen in just the past few years.

Limitations of current guidelines include:
•       No mention of fidaxomicin, a narrow-spectrum antibiotic, which in 2011 was the first medication approved in 25 years for the treatment of C. diff associated diarrhea
•       Limited evidence for recommendations to treat severe, complicated CDI
•       Limited evidence for recommendations on recurrent CDI
•       Little mention of Fecal Microbiota Transplant (FMT)

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5.  Patient advocacy and awareness efforts can alter the course of CDI.
CDI survivors shared their experiences along their emotional journey – fear, disbelief, isolation, and depression. They also expressed gratitude at the validation, information and support they received from the patient advocacy community. Perhaps the greatest gift they have received is the empowerment to question their physicians about the necessity of antibiotics they have been prescribed in terms of risk of CDI.

“The hospital where I was treated initially seemed eager to have me leave. They offered no additional help. The C diff Foundation has been my greatest source of help. In turn, I feel I help myself cope best, when I help others to cope with the disease,” said Poole.

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Dale Gerding, MD, FACP, FIDSA, is Professor of Medicine at Loyola University Chicago, Research Physician at the Edward Hines Jr. VA Hospital. Additionally, Gerding is an infectious disease specialist and hospital epidemiologist, past president of the Society for Healthcare Epidemiology of America and past chair of the antibiotic resistance committee of SHEA. He is a fellow of the Infectious Diseases Society of America and past chair of the National and Global Public Health Committee and the Antibiotic Resistance Subcommittee of IDSA. His research interests include the epidemiology and prevention of Clostridium difficile, antimicrobial resistance, and antimicrobial distribution and kinetics.

The paper, “Burden of Clostridium difficile Infection in the United States,” was published in the New England Journal of Medicine.

The study, “Changing epidemiology of Clostridium difficile infection following the intriduction of a national ribotyping-based surveillance scheme in England,” was published in the journal Clinical Infectious Diseases.

The study, “Prevalence of antimicrobial use in US acute care hospitals,” was published in JAMA.

The paper, “Vancomycin, metronidazole, or toleyamer for Clostridium difficile infection: results from two multinaionalm randomized, controlled trials,” was published in Clinical Infectious Diseases.

The study, “A Randomized Placebo-controlled Trial of Saccharomyces boulardii in Combination with Standard Antibiotics for Clostridium difficile disease,” was published in JAMA.

Perspective and Key Issues Regarding Healthcare Textiles and Infection Prevention Q&A With Infection Control Today + Healthcare Laundry Accreditation Council

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Infection Control Today (ICT) asked board members of the Healthcare Laundry Accreditation Council (HLAC) for their perspectives on key issues relating to infection prevention and healthcare textiles management.

 

 

Q: What are the gaps in research that are needed to advance healthcare textile science?
A: We view gaps as opportunities for advancements in healthcare textile science, and these opportunities are in large part being driven by infection prevention’s changing landscape. Growing drug resistance, the threat of pandemics and the cost of healthcare-associated infections (HAIs) require that we gain a much better understanding of the morphology of organisms as it relates to their resistance and the chain of transmission. The list of infectious agents continues to grow and include prions, Clostridium difficile (C. diff.), Severe Acute Respiratory Syndrome (SARS), Ebola, etc. Each is unique and presents its own challenges for healthcare textiles, including the need to protect patient and staff from exposure situations (e.g., via personal protective equipment), assisting in patient-care activities (from exam gowns to incontinence products), and ultimately the need for them to be effectively cleaned/sanitized for reuse. The emergency guidelines issued by the Centers for Disease Control and Prevention (CDC) for Ebola highlight the point: all items including textiles exposed to an Ebola patient must be incinerated. Though it is a very pragmatic and understandable decision, it is not an effective or sustainable one.
A better understanding of these infectious agents will allow for:
– The development of barrier fabrics that include chemical finishes that offer better and more specialized protection for the wearer
– Optimized cleaning and sanitizing conditions in the reprocessing of reusable products
– The use of scientifically based guidelines (not emotional ones) that effectively mitigate (not displace) infection risk in the handling contaminated textiles – (i.e., exposure of waste handlers vs. handling by trained reprocessing professionals).
— Bradley J. Bushman, vice president of technical affairs, Standard Textile Co. Inc., Cincinnati, Ohio

Q: What are the imperatives about proper healthcare laundry processes that infection preventionists (IPs) must know?
A: IPs must be well-versed in the end-to-end healthcare laundry process, especially in the context of potential infection risks from contaminated healthcare textiles (HCTs). Contamination risks extend well beyond the actual wash process. While it is imperative to have a validated wash process that consistently produces hygienically safe and clean textiles, close attention must be paid to the many contamination risks after the wash process. HCT contamination after the wash process is just as dangerous as contamination from improperly washed HCTs.
Key areas to look for potential HCT contamination include:
– Dirty finish surfaces that may touch clean HCTs
– Carts, after being loaded, that are improperly stored outside on a loading dock
– HCT transfer carts that are not protected from the environment via fluid-proof covers or doors
– Dirty hands of laundry workers handling clean HCTs
– Dirty/linty equipment used to process HCTs
– The presence of dirty/soiled HCTs in an area with clean HCT
– Contaminated air flowing into a clean HCT area.
Also, it’s imperative to ensure that laundry workers are well-trained in hygiene concepts such as proper hand hygiene; proper environmental cleaning; the importance of functional separation of soiled and clean; and proper HCT sorting, washing, drying, and finishing.
— Gregory Gicewicz, HLAC immediate past president; president, Sterile Surgical Systems, Tumwater, Wash.

Q: How important is it for healthcare laundry personnel to work with IPs and other stakeholders to achieve good outcomes?
A: It is very important. It’s essential to have open communication and collaboration between the healthcare IP and the laundry profession. There must be a sharing of knowledge and operational details, both the laundry operations and the healthcare facility operation, for each professional to be able to positively interact with each other.
The IP is involved in and responsible for observation, or surveillance, of aspects relating to both patient safety and infection prevention. This includes the collection and analysis of infection prevention and control data; review of products and procedures; follow-up on infection risk; prevention and control approaches; educational interventions to avoid or mitigate infection; and the application of changes mandated by regulatory and licensing agencies such as the Occupational Health and Safety Administration (OSHA). The more knowledge the IP has concerning the operations of a laundry, the more epidemiological principles can be applied to improve patient care outcomes.
In welcoming the IP, a bond can be established that allows both entities to address ongoing issues with desired outcomes. Utilizing observation to follow the laundry progression of textiles in a step-by-step process will enable the IP to determine if there are perceived breaches in the process and can share these concerns with the laundry operator and personnel. In turn, the healthcare laundry operator may notify the healthcare facility administration and IP of concerns they may encounter in the healthcare laundry.
— Joan Blanchard, RN, MSS, CNOR, CIC, infection prevention assistant, Littleton Adventist Hospital, Littleton, Colo.

Q: What are some ways that IPs can help facilitate dialogue and collaboration with healthcare laundry professionals?
A: We encourage IPs to have a strong, trusted partnership with their healthcare laundry vendor. A good practice is for the hospital IP team members to treat their healthcare laundry professionals as part of their extended team, where there’s an ongoing sharing of updates in infection control and prevention efforts and in the regulatory and licensing arenas. By establishing a working relationship with healthcare laundry personnel, problems that arise with the laundry process or the healthcare facility process can be more readily corrected and unresolved issues can be more directly addressed.
Important to this team-style relationship is for the IP to visit the healthcare laundry to become acquainted with the personnel responsible for administering the laundry. In fact, the laundry should be open to at least yearly visits from their IPs. These visits are more productive when they’re treated collaboratively. The purpose of visits is to ensure that the processes used by the healthcare laundry is safe and supported by research*. Utilizing HLAC’s Standards Checklist (available at www.hlacnet.org) as a guideline during these visits ensures that a thorough over-view of the laundry process is accomplished.
— Gregory Gicewicz, HLAC immediate past president; president, Sterile Surgical Systems, Tumwater, Wash.; and Joan Blanchard, RN, MSS, CNOR, CIC, infection prevention assistant, Littleton Adventist Hospital, Littleton, Colo.

Q: What are the unresolved key issues related to infection prevention and healthcare textiles that remain for the future?
A: Without education and awareness, the same myths about healthcare laundry that have persisted for a long time will continue. For example:
– Myth: The laundry industry is regulated – by someone.
– Myth: The laundry industry is regulated by the government.
– Myth: If the hospital is accredited then so is the laundry.
– Myth: All textiles are washed the same.
– Myth: When it comes to knowing all about laundry matters, the hospital IP is on top of it.
– Myth: Every healthcare laundry is accredited.
Only the education of healthcare professionals, including IPs, can overcome these myths.
Furthermore, in the expanding world of pathogens, we will continue to see more bacteria and viruses developing more lethal strains and antibiotics becoming less and less effective. HLAC believes that going forward we should be striving for a more robust, collaborative effort among healthcare laundries, IPs, environmental services, laundry departments, quality management, and healthcare resource and materials management professionals.
Another point: It’s not unrealistic for hospitals to begin to look at healthcare textiles as an investment in quality patient outcomes and not just an expense. Bear in mind that the processing of healthcare textiles is a reimbursable expense by CMS because healthcare textiles have a direct impact on patient outcomes.
Because of these issues, we believe that every laundry that is providing healthcare textile processing services should be HLAC-accredited. Doing so would ensure that all patients receive textiles that are processed to the highest level, thus safeguarding that three of the four major principles of medical ethics are afforded of all patients: Justice, beneficence, and non-maleficence. We believe that there is a moral and ethical obligation to do the right thing for patients and processing healthcare textiles to the highest level possible helps to fulfill those obligations. We believe that working collaboratively, IPs and laundry operators will be key players in this process.
— Joan Blanchard, RN, MSS, CNOR, CIC, infection prevention assistant, Littleton Adventist Hospital, Littleton, Colo.; and John Scherberger, HLAC board president; president, Healthcare Risk Mitigation, Spartanburg, S.C.

References:
1. Centers for Medicare/Medicaid Services. CMS Hospital Infection Control Worksheet. https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GenInfo/Downloads/Survey-and-Cert-Letter-15-12-Attachment-1.pdf Accessed July 14, 2016.
2. Occupational Safety and Health Administration. Toxic and Hazardous Substances: Bloodborne Pathogens, 29 CFR § 1030 (2012). Occupational Safety and Health Administration.
3. Siegel JD, Rhinehart E, Jackson M, Chierello L. the Healthcare Infection Control Practices Committee. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. 2007.
4. Accreditation Standards for Processing Reusable Textiles for use in Healthcare Facilities. 2016 ed Frankfort, IL. Health care Laundry Accreditation Council. 2016.
5. Protecting Workers Families—DHHS(NIOSH) Pub No. 1002-113. National Institute for Occupational Safety and Health.
6. AINSI/AAMI ST65 2008/R 2013 Processing of Reusable Surgical Textiles for Use in Healthcare Facilities. 2013. Arlington, VA.: Association for the Advancement of Medical Instrumentation: 2013.
7. Guideline for Surgical Attire. In: Guidelines for Perioperative. Denver, CO: AORN, Inc.: 2016.

RESOURCE:

http://www.infectioncontroltoday.com/articles/2016/09/hlac-board-members-address-imperatives-related-to-healthcare-textiles.aspx