infection transmission is a contact sport · 2020-04-07 · infection transmission is a contact...
TRANSCRIPT
INFECTION TRANSMISSION IS A CONTACT SPORT
Presented by:Kim H. Neiman MPH, BSN, RN, CIC
DISCLOSURE
• I am a paid employee of the clinical team of PDI Healthcare.
The content of this presentation is not representative of the
views of PDI or its ownership.
• There will be NO discussion of any PDI products and/or
solutions in accordance with CE Requirements.
• Presentation will incorporate best practices from a variety of
information sources that bridge medical disciplines.
AFFILIATIONS
• Member of the Association for Professionals in Infection
Control and Epidemiology (APIC)
Member of APIC Southern Nevada and APIC Sierra
chapters
• Member of the Northern Nevada Infection Control (NNIC)
network
• Member of the Infusion Nurses Society (INS)
• Member and Industry partner of the Association for
Vascular Access (AVA)
PROGRAM OBJECTIVES
• Understand the role of surface disinfection in
healthcare today
• Describe recommendations for special pathogens
• Discuss current disinfection & prevention
technology and factors to consider when choosing
disinfectants
IS INFECTION TRANSMISSION A CONTACT SPORT?
Patient(s) contaminate surfaces or medical equipment
Environmental surfaces/inanimate objects are reservoirs (fomites)
Healthcare workers contact contaminated surface & patients
Environmental Contamination + Poor Hand Hygiene
Contributes to the spread of resistant pathogens
THE DIRTY DOZEN
Kitchen Sink
Airplane bathrooms
Wet laundry
Public drinking fountains
Shopping cart handles
ATM buttons
Women’s purse
Playgrounds
Health club (mats/machines)
Your bathtub
Office telephone
Hotel Room Remote
HIGH TOUCH SURFACE CLEANING EVALUATION
ICHE 2007 29(1):1–7
Figure 1. Overall percentage of high risk objects determined to have been cleaned in each of the 23 acute care hospitals
ICHE 2010, 31:850-853.
FREQUENCY OF WORKER CONTACT OF
CONTAMINATED ENVIRONMENTAL SURFACES
UNDERSTANDING REGULATIONS
0
WHAT DOES THIS MEAN TO YOU?
EPA CATEGORY - DISINFECTANTS
• DISINFECTANT: an agent that destroys or irreversibly inactivates infectious or other undesirable bacteria, pathogenic, or viruses, but not necessarily bacterial spores, on surfaces or inanimate objects
EPA registers three types of disinfectant products based upon submitted efficacy data
• LIMITED DISINFECTANT: Agent limited to either gram-positive or gram-negative microorganisms.
Example: Pine oil toilet bowel products effective against gram-negative bacteria
• GENERAL OR BROAD SPECTRUM DISINFECTANT: Agent that is effective against both gram-positive and gram-negative bacteria
Most household disinfectants and disinfectants for swimming pools and water purifiers
EPA CATEGORY - DISINFECTANTS
• HOSPITAL DISINFECTANT: An agent effective against:
−Gram negative organism (Salmonella choleraesuis)
−Gram positive organism (Staphylococcus aureus)
−Pseudomonas aeruginosa
Contains certain claims that it destroys or eliminates all forms of microbial life in the inanimate environment, including all forms of vegetative bacteria, bacterial spores, fungi, fungal spores, and viruses
• Used in all healthcare facilities
• Virucide claim: product must be effective against specific virus the company wishes to list on label
• Tuberculocide claim: product must be effective against a Mycobacterium that EPA accepts as a surrogate for the actual tuberculosis bacterium
• Fungicidal claim: product must be effective against Trichophyton mentagraphites
EPA CATEGORY - DISINFECTANTS
• SANITIZER: Agent that reduces, but does not necessarily
eliminate, the microorganisms in the inanimate environment
to levels considered safe by public health codes or other
regulations
−EPA registers many sanitizers i.e., non food contact surfaces, food
contact surfaces
−Performance standard for food contact surfaces is 99.999% (5-log
reduction) within 30 sec
−Performance standard for non-food use sanitizer is 99.9% (3-log)
reduction in 5 min
KILL CLAIMS VS. CONTACT TIMES
KILL CLAIM: Defined when a disinfectant
product is tested to have 100% efficacy
against a specific organism at a
determined contact time; and the testing
data has been accepted by the EPA
Bridging of Data for Label Claims – What
does this mean?
Similar product application
KILL CLAIMS VS. CONTACT TIMES CONTINUED
•Contact Time: The time needed for the
germicide solution to remain wet on the
surface to achieve disinfection of the stated
kill claims on the manufacturer’s label
−General directions for use: requires manufacturers to
place highest contact time in those directions.
−“Special Instructions for Bloodborne Pathogens” may
include special directions such as lower contact time for
targeting these organisms (e.g. HIV, HBV, HCV).
MECHANISM OF ACTION - DISINFECTANT
SURFACE DISINFECTANTS• Disinfectants typically have a
positive charge
• Gram-negative bacteria typically
have a negative chargeDisinfectant is drawn to the bacteria
Gram negative
bacilliDisinfectant
Disinfectant then…
• Attacks and adsorbs through the cell wall
• disrupts the cell membrane which release
potassium ions and other cell componentsResults in cell death
Block, Fifth Edition
Gram neg
baci
ative
lli
CONTACT TIME
“ Disinfect noncritical surfaces with an EPA-registered hospital disinfectant using the label’s safety precautions and use directions. Most EPA-registered hospital disinfectants have a label contact time of 10 minutes. However, many scientific studies have demonstrated the efficacy of hospital disinfectants against pathogens with a contact time of at least 1 minute. By law, the user must follow all applicable label instructions on EPA-registered products. If the user selects exposure conditions that differ from those of EPA-registered products label, the user assumes liability for any injuries resulting from off-label use and is potentially subject to enforcement action under FIFRA”
Rutala, W. Disinfection, Sterilization and Antisepsis Principles, Practices, Current
Issues, New Research, & New Technologies. APIC Conference Proceedings, 2010 Ed. Pg 9
INFLUENCING FACTORS FOR DISINFECTION EFFICACY
•Cleaning of object
•Bioburden (organic or inorganic load present)
•Type and level of organism contamination
•Concentration of product
•Exposure time
•Nature of object
•Temperature and relative humidity
DISINFECTANTS USED IN HEALTHCARE*(INTERMEDIATE-LOW LEVEL)
•Phenolics
•Quaternary ammonium compounds
• Iodophors
•Alcohols
•Chlorine and chlorine compounds
•Combination e.g., Alc/Quat
•Hydrogen peroxide
Disinfectants are not interchangeable. Select an
appropriate disinfectant for any item and use.
Caution: some disinfectants may cause respiratory
breathing problems (e.g. chlorines)
APPROACH TO DISINFECTION ANDSTERILIZATION
Spaulding’s Classification: >30 yrs old
•CRITICAL ITEMS: High risk of infection –
sterile tissue
•SEMI-CRITICAL ITEMS: Contact with
mucous membranes or non-intact skin
•NON-CRITICAL ITEMS: Contact with intact
skin (environmental disinfection; inanimate
objects)
LEVELS OF DISINFECTION
•STERILIZATION
•HIGH-LEVEL DISINFECTION: Expected to destroy all microorganisms except high numbers of bacterial spores
• INTERMEDIATE-LEVEL DISINFECTION: Inactivates Mycobacterium tuberculosis, vegetative bacteria, most viruses, most fungi.
•LOW-LEVEL DISINFECTION: Can kill most bacteria, some viruses, and some fungi, but cannot be relied on to kill resistant microorganisms such as tubercle bacilli or bacterial spores
BACTERIALSPORES
MYCOBACTERIUM
NON LIPID VIRUSES
FUNGI
VEGATIVE BACTERIA
LIPID VIRUSES
Descending Order of Resistance to Germicidal Chemicals.
Rutala, W. APIC Guideline for Selection & Use of Disinfectants-1996
NEW CONCEPT FOR ORGANISM LIST
• Prions
• Bacterial spores (C. difficile)
• Protozoan oocysts
• Helminth eggs
• Small, non-enveloped viruses (Norovirus)
• Mycobacteria
• Protozoan cysts
• Fungal spores
• Gram negative bacilli (Acinetobacter, ESBL E. Coli, KPC)
• Vegetative fungi and algae
• Large, non-enveloped viruses
• Gram positive bacilli (MRSA, VRE)
• Enveloped viruses
Weber, DJ. Role of the Environment in the Development of Hospital-Acquired Infection: A Critical Review of the Evidence,
ID WEEK, Session 0003.
Difficult
Easier
PATHOGENS OF CONCERN
VIRUSES
•Generally transmitted by fecal-oral route and contaminated fomites
•Sturdy
•Can withstand drying, effects of detergents, extremes of pH, and temperature
•Can withstand acid environment of stomach
•Fragile (they require an intact envelop for infectivity)
•Must remain wet and are spread in:
− Respiratory droplets, blood, mucus, saliva, and semen
− Injection
− organ transplants
NON-ENVELOPED (non-lipid) ENVELOPED (lipid)
Murphy, Rosenthal, Pfaller. Medical Microbiology 5th Ed Chapter 29,
pp. 499-500. 2005.
VIRUSES
NON-ENVELOPED (non lipid)
•Norwalk Virus/Norovirus
(Caliciviridae)
•Adenovirus
•Rhinovirus
•Rotavirus
•Enterovirus
•Hep A
ENVELOPED (lipid)
•Herpes Simplex
•HIV
•CMG
• Influenza
•Coronavirus
•Hep B, C
•RSV
VEGETATIVE BACTERIA
•MRSA
•VRE
•ESBL producing E. Coli; Klebsiella pneumoniae
•Carbapenem-Resistant Enterobacteriaceae (CRE)
•Acinetobacter baumanii
•Pseudomonas aeruginosa
•E. Coli 0157:H7
Clostridium difficile
INACTIVATION OF C. DIFFICILE
•C. difficile spores are more resistant than vegetative cells to commonly used surface disinfectants
•Environment may be an important source of C. difficile spores
•Three EPA-registered products specific for inactivating C. difficile spores
•Recommendations: Use of diluted sodium hypochlorite (1:10 dilution of bleach) in units with high endemic rates and outbreaks1
1Rutala, W. Disinfection, Sterilization and Antisepsis Principles, Practices, Current
Issues and New Research. APIC Conference Proceedings, 2010. Page 127-132.
CLOSTRIDIA DIFFICILE (CONTINUED)
2008 EPA MANDATES
•EPA has determined all pesticide products that are registered for use against C. difficile must demonstrate efficacious performance against the spore form
•Vegetative form is not the organism of concern for infection control processes
•Efficacy testing performed on the vegetative form of the organism will not support a claim for C. difficile spores
•EPA notified manufacturers with vegetative label claims to remove these claims
•EPA has developed guidelines to address label claims for C. difficile spores
In units with high rates of endemic Clostridium
difficile infection or in an outbreak setting, use dilute
solutions of 5.25%–6.15% sodium hypochlorite (e.g.,
1:10 dilution of bleach) for routine environmental
disinfection.
Note that there are now EPA registered products
available that have claims for C. difficile spores.
CLOSTRIDIUM DIFFICILE
2008 CDC Guidelines for Disinfection & Sterilization
CURRENT PRACTICE
Clean noncritical medical equipment surfaces with a
detergent/disinfectant.
May be followed by an application of an EPA-
registered hospital disinfectant with or without a
tuberculocidal claim, in accordance with germicide
label instructions
Do not use alcohol to disinfect large environmental
surfaces
Clean and disinfect high-touch surfaces (e.g.,
doorknobs, bed rails, light switches, and surfaces in
and around toilets in patients' rooms) on a more
frequent schedule than minimal- touch
housekeeping surfaces.
2008 CDC Guidelines for Disinfection & Sterilization
• Thoroughly clean and disinfect environmental and
medical equipment surfaces on a regular basis by
using EPA-registered disinfectants in accordance
with manufacturers' instructions
• Do not use high-level disinfectants (i.e., liquid
chemical sterilants) on environmental surfaces; such
use is inconsistent with label instructions because of
the toxicity of the chemicals
• Use standard cleaning and disinfection protocols to
control environmental contamination with antibiotic-
resistant, gram-positive cocci (e.g MRSA, VRE)
organisms.
CDC RECOMMENDATIONS FOR
SPECIAL ORGANISMS
2008 CDC Guidelines for Disinfection & Sterilization
AHE 2008 & 2012 PRACTICE GUIDELINES
• Establish cleaning checklists
• Disinfectants should be applied using pour bottles, not sprays.
• Never re-immerse cloth (cloth & bucket systems)
• Cotton decreases efficacy of Quats
• Establish who cleans what and how
EVS Staff
Nursing Staff
• Clean and disinfect as usual for C. diff and then disinfect high touch areas with bleach
• Understand which products are compatible with equipment
• Training (new hire, annual, as needed)
www.ahe.org
Approach to Emerging Pathogens
Stringent Hand
Hygiene
Routine Cleaning
Daily and Terminal
Disinfection
Isolation Precautions
PPE Prevention
Pathogen Specific
Approach
General EPA-Registered Disinfectant
DISINFECTANT
SELECTION
CURRENT DISINFECTANTS
•Quaternary ammonium compounds
•Quaternary/Alcohol formulations
•Sodium hypochlorite formulations (bleach)
•Phenolics
•Hydrogen Peroxide formulation(s)
New Technology: Accelerated Hydrogen
Peroxide, UV Light, Copper, Silver
SELECTING DISINFECTANTS
A dilemma for Facilities•Many types of equipment and end users
•Confusion about regulatory compliance (CMS, TJC)
•IC involvement in product and equipment selection?
Focus on Practice or Product or Both?• Monitor Practices
• Education of staff and their involvement in prevention initiatives
• Who is responsible for cleaning/disinfecting environmental surfaces and equipment?
SELECTING DISINFECTANTS CONTINUED
•Should one disinfectant be used hospital-wide?
•Medical equipment specifying specific product to use (e.g., IV pumps, Patient Monitoring Equipment)
•Consider safety and precautionary factors
•Consider stability and shelf life of product
•Consider convenience and ease of use
GOING GREEN?
•Hospitals moving toward green initiatives
− building materials
− lighting
− water usage (more efficient toilets, faucets)
•Insure “green” initiatives don’t inadvertently place infection control and prevention efforts at risk
•Green cleaners are “cleaners” – not approved for hospital disinfectant
Summer 2008 Prevention Strategist (APIC), “Finding a Balance”.
NEW TECHNOLOGY
Copper and Silver impregnated materials:•Lack of consensus on percentage required for effectiveness
•Has not been proven to reduce the incidence of HCAIs
Automated Room Disinfection Systems:
Aim is to improve disinfection, remove/reduce operator reliance,
prevent increased risk from prior room occupant
UV-C radiation: Use as an adjunctive disinfectant, does
not show reproducible significant reduction of bacterial
contamination to date, costly.
Hydrogen Peroxide Vapor Aerosolization: Improves
disinfection, costly, time consuming.
Role of Ultraviolet (UV) Disinfection in IC and Environmental Cleaning. Appl Environ Microbiol2013 Feb;79(4):1325-32.
J. O’Gorman, H, Humphreys. Application of copper to prevent & control infection. Where are we now? J Hosp infect. 2012 Aug;81(4):217-23 .
The role of “no touch” automated room disinfection systems in Infection prevention & control. J. Hosp Infect 2013 Jan;83(1)1-13.
Efficacy, efficiency,& safety aspects of hydrogen peroxide vapor & aerosolized hydrogen peroxide room disinfection systems. F.TY et al. J Hosp
Infect. 2012 Mar;80(3):199-205
NEW TECHNOLOGY –UNANSWERED QUESTIONS
Cleaning process before disinfection
Room turnover
Assessment
Cost
Responsibility
Maintenance and Repair
Lifespan
• F. Barbut et.al. Infect Control Hosp Epidemiol. 2009 Jun;30(6):507-14.
• TI Fu et.al. J Hosp Infect. 2012 Mar;80(3):199-205.
• Destrez P. J Hosp Infect. 2012 Sep; 82(1):68.
EVALUATION OF ENVIRONMENTAL CLEANING
http://www.cdc.gov/hai/toolkits/evaluating-environmental-cleaning.html
Evaluating
Checklists
Improved thoroughness of cleaning results in: Decreased infections (improved patient outcomes)
Decreased cost (HAIs often not reimbursable; 1 HAI equivalent to EVS
FTE!)
Improved patient satisfaction (patients equate dirty rooms with poor
care)
Meets CMS/TJC requirements
PRACTICE MONITORING
Visual Assessment: Not a reliable indicator of
surface cleanliness
Microbiological Methods: What are acceptable
results (<2.5 CFUs/cm2 pass?), costly, pathogen
specific
ATP bioluminescence: Measures organic debris
(alive & dead), does not detect viruses, each unit
has own reading scale (<250-500 RLU), chlorine
(bleach) gives false “zero” reading
Fluorescent Marker: Pre-placement of markers is
time consuming, punitive, good teaching tool
O Sherlock et.al. Is it really clean? An evaluation of the efficacy of four methods for determining hospital cleanliness. J Hosp Infect. 2009 Jun;72(2):140-6.
E Brown, et.al. Do surface and cleaning chemistries interfere with ATP measurement systems for monitoring patient room hygiene? J Hosp Infect.2010 Feb;74(2):193-5.
G. Moore, et.al. The use of adenosine triphosphate bioluminescence to assess the efficacy of a modified cleaning program implemented within an intensive care setting.
Am J Infect Control.2010 Oct;38(8):617-22.
D. Mulvey, et.al. Finding a benchmark for monitoring hospital cleanliness. J Hosp Infect.2011 Jan;77(1):25-30.
L. Luick, et.al. Diagnostic assessment of different environmental cleaning monitoring methods. Am J Infect Control. 2013 Aug;41(8):751-2.
SUMMARY
The environment and fomites play a role in infection transmission thus a “contact sport”.
Understanding the rules and regulations for surface disinfectants, kill claims, contact times and product labels is key to making good choices in selecting disinfectants.
In dealing with problem pathogens, understand that it is important to focus on practices & products.
QUESTIONS
ADDED REFERENCES
• CDC Guideline for disinfection and sterilization in healthcare facilities., 2008 . Available at: http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Disinfection_Nov_2008.pdf
• CDC Guidelines for environmental infection control in healthcare facilities. MMWR 2003:52(RR 10):1-42. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5210a1.htm
• Murphy, Rosenthal, Pfaller. Medical Microbiology 5th Ed Chapter 29, pp. 499-500. 2005.
• Rutala, W. APIC Disinfection, Sterilization and Antisepsis: Principles, Practices, Current Issues, New Research and New Technologies. 2010 Edition.
• Spaulding EH. Chemical disinfection of medical and surgical materials. In: Lawrence C, Block S S, eds. Disinfection, Sterilization and Preservation. Philadelphia: Lea & Febiger, 1968:517-531.