are gloves required when caring for patients with...
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Are gloves required when caring
for patients with VRE?
School of Public Health and Community Medicine
Prof Mary-Louise McLaws and Susan Jain
University of New south Wales,
SPHCM Samuels Building Level 3,
UNSW Australia, Sydney, NSW 2052
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The Purpose of Nonsterile Gloves (NSG)
HIV
• Emergence highlighted need to prevent BBV transmission
• Principle strategy introduced involved NSG regardless of
infection status
• Additional protection against BBV-sharps injury
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How did NSGs become the norm for contact
precautions?
• 1996 CDC Standard Precautions (SP) and Transmission
based Precautions (Contact, Droplet and Airborne)
- emergence of multidrug resistant organisms (MDROs)
• Adopted by Australian NHMRC and Infection Preventions
and Control policy
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Pros - NSG for VRE
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Vancomycin Resistant Enterococci (VRE)
• Enterococci
normal flora - lower gastro-intestinal tract
other body sites - skin surfaces, vagina, urethra,
hepatobiliary tree
• Most patients VRE colonised not infected
• Colonised patient VRE in faeces
• Prolonged survival in patient zone
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Risk Factors for VRE Transmission
• Diarrhoea or faecal incontinence
• Enterostomies
• VRE discharging wounds
• Incontinence - VRE colonisation urinary tract
• Inability to maintain own personal hygiene
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Routes of VRE transmission
• Direct contact - transient VRE carriage via HCWs’ hands
or
• Indirectly - contaminated environmental surfaces/shared
equipment
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Magill SS et al. N Engl J Med 2014;370:1198-1208.
Multistate Point Prevalence Survey of Health Care Associated
Infections 2014
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How should we manage VRE patients ?
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CP-Current Guidelines for VRE
• Perform hand hygiene
• Don gloves and gown (PPE) on entry to patient-care
zone
• Ensure HCWs’ clothing and skin have no contact with
environmental surfaces
• Before leaving zone: doff PPE, perform hand hygiene
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Pros of NSG Use when Patients under VRE
Precautions
• HCWs sense of self protection
• Protection from significant amount of BBF
• Potential for decreased transmission of microorganisms
to environment
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Respondents had positive attitudes towards:
• use of gloves to protect against acquiring an infection at
work
• the availability of gloves
• acting as a role model to other staff
Overall good knowledge of glove use (83%)
Journal of Infection Prevention 2006 London
Healthcare workers' knowledge and attitudes to
glove use
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Controlling VRE-What works?
• Larson (2000) increased handwashing associated 85%
risk reduction VRE infection rates
• Pittet (2000) increased hand disinfection compliance
48% to 66% (P <0 .001) over a 3-year period associated
with decrease in the HAI prevalence 16.9% to 9.9%
(P =0.04)
• Bonten (1996) effective environmental decontamination
important in control VRE transmission
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Cons - NSG for VRE
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Crit Care Med. 2012 April ; 40(4): 1045–1051. doi:10.1097/CCM.0b013e31823bc7c8.
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NSG - Role in VRE Prevalence
• Tenorio (2001)
39% gloves positive VRE after having contact with VRE
colonized/infected patient
hand hygiene not performed before & after glove use
• Hayden (2008)
52% contaminated gloved & ungloved hands after
touching zone VRE-colonized patient
70% contamination after touching both patient and zone
hand hygiene not performed before & after sampling
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More Evidence
• Snyder (2008) 13% gowns and/or gloves acquired
MRSA and/or VRE and MRSA on hands after removing
gowns/gloves
• reinforces importance of handwashing after all HCW-
patient interactions
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Rates of compliance with hand hygiene demonstrate
decreasing VRE prevalence.
Emilian Armeanu et al. Clin Infect Dis. 2005;41:210-216 The Netherlands
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The non-evidential emotionally driven practices
of NSG use
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NSG - Impact on Hand Hygiene
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Consequences of gloves misuse in terms of percentage of hand hygiene opportunities missed (■) and potential for
microbial transmission ( *P=0.0008 versus medical wards, **P=0.01 versus nursing assistants, and P=0.0002 versus
nursing assistants.
E. Girou, S.H.T. Chai, F. Oppein, P. Legrand, D.
Ducellier, F. Cizeau, C. Brun-Buisson (2004)
Misuse of gloves: the foundation for poor compliance with
hand hygiene and potential for microbial transmission?
Hand hygiene was not undertaken due to
improper gloving in 64.4% (95%CI, 64.1%
to 65.1%) of instances.
Possible microbial transmission might
have occurred in 18.3% (95%CI, 17.8% to
18.8%) of all contacts because used
gloves were not removed before
performing care activities that
necessitated strict aseptic precautions.
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Mandatory NSG Eliminated from CP
• Cusini (2015) HH compliance for contact precautions
52% 2009 vs 85% 2012 (P < 0.001)
• Increased HH compliance before invasive procedures
and before patient contacts
• Marshall (2004), Katherason (2010), Naderi (2012),
Loveday (2014), Wilson (2015) mandatory NSG use
sacrifices hand hygiene
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Innovative approach by Seto Wing Hong
• “Up till the present we know of no infectious material that can
penetrate the intact skin”
• Infectious material on hands harmful if subsequently touch mucous
membrane e.g. eyes
• Gloves should be worn for tasks with significant hand contamination
(e.g. blood or body fluid contact) because subsequent hand
hygiene may not remove all the infectious material
• Regular hand hygiene to remove these infectious materials best
protection
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Integrating ‘My 5MHH’ and NSG Use??
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Role of hand hygiene and environmental cleaning
• Are we saying that My 5MHH isn’t enough when a
patient is colonised with VRE or that we can’t rely on
hand hygiene?
• Aren’t we sure about the decrease in bioburden by
environmental cleaning?
• What about cleaning of shared equipment? What role
does it plays in the cross transmission?
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What will happen if we removed NSG from wards
for continent patients ?
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Make Sensible Decisions
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Reference • J Wilson, S Lynam, J Singleto3, H Loveday, 2013 The misuse of clinical gloves: risk of
cross-infection and factors influencing the decision of healthcare workers to wear gloves
• Girou, E., Chaia, S,h, T, Oppeina, F, Legrandb, P, Ducelliera, D, Cizeaua, F And Brun-Buisson, C. 2004. Misuse of gloves: the foundation for poor compliance with hand hygiene and potential for microbial transmission? Journal of Hospital Infection, 57.
• Katherason, S., G, Naing, L, Jaalam, K, Mohamad, N, A, N, Bhojwani, K, Harussani, K And Ismail, A 2010. Hand decontamination practices and the appropriate use of gloves in two adult intensive care units in Malaysia. Journal of Infection in Developing Countries, 4.
• Fuller, C., Savage, J, Besser, S, Hayward, A, Cookson, B, Cooper,b And Stone, S 2011. The Dirty Hand in the Latex Glove: A Study of Hand Hygiene Compliance When Gloves Are Worn. Infection Control and Hospital Epidemiology, 32.
• Naderi, H. S., F. Mostafavi, I. And Khosravi, N. 2012. Compliance with hand hygiene and glove change in a general hospital, Mashhad, Iran: An observational study. American Journal of Infection Control, 40, 221.
• Tenorio, et al (2001) Effectiveness of Gloves in the Prevention of Hand Carriage of Vancomycin-Resistant Enterococcus Species by Health Care Workers after Patient Care http://cid.oxfordjournals.org/content/32/5/826.long
• Hayden et al (2008) Risk of Hand or Glove Contamination After Contact With Patients Colonized With Vancomycin-Resistant Enterococcus or the Colonized Patients’ Environment http://www.jstor.org.wwwproxy1.library.unsw.edu.au/stable/pdf/10.1086/524331.pdf
• Snyder et al (2008) Detection of Methicillin-Resistant Staphylococcus aureus and Vancomycin-Resistant Enterococci on the Gowns and Gloves of Healthcare Workers