Decontamination approaches and strategies for the prevention of sink drain-related healthcare-associated infections.

Role of Sinks as an Environmental Reservoir in CPE Outbreak in a Burn Intensive Care Unit

Responsibility for managing healthcare-associated infections: where does the buck stop?

Sink drainage systems are not amenable to standard methods of cleaning and disinfection. Disinfectants applied as a foam might enhance efficacy of drain decontamination due to greater persistence and increased penetration into sites harboring microorganisms. To examine the efficacy and persistence of foam-based products in reducing sink drain colonization with gram-negative bacilli. During a 5-month period, different methods for sink drain disinfection in patient rooms were evaluated in a hospital and its affiliated long-term care facility. We compared the efficacy of a single treatment with 4 different foam products in reducing the burden of gram-negative bacilli in the sink drain to a depth of 2.4 cm (1 inch) below the strainer. For the most effective product, the effectiveness of foam versus liquid-pouring applications, and the effectiveness of repeated foam treatments were evaluated. A foam product containing 3.13% hydrogen peroxide and 0.05% peracetic acid was significantly more effective than the other 3 foam products. In comparison to pouring the hydrogen peroxide and peracetic acid disinfectant, the foam application resulted in significantly reduced recovery of gram-negative bacilli on days 1, 2, and 3 after treatment with a return to baseline by day 7. With repeated treatments every 3 days, a progressive decrease in the bacterial load recovered from sink drains was achieved. An easy-to-use foaming application of a hydrogen peroxide- and peracetic acid-based disinfectant suppressed sink-drain colonization for at least 3 days. Intermittent application of the foaming disinfectant could potentially reduce the risk for dissemination of pathogens from sink drains.

Background: Between January and September 2022, 10 patients who were admitted to the Intensive Care Unit (ICU) for a period of more than 72 hours were found to have carbapenemase-producing Enterobacteriaceae (CPE) in their screening/clinical specimens. No epidemiological association was found among them, and none had received healthcare outside Canada in the preceding 12 months. The study investigated whether sink drains could be a source of CPE transmission. Methods: A retrospective study was conducted on all patients admitted to the ICU during the surveillance period who tested positive for CPE, alongside a pilot study involving environmental screening cultures collected from hand hygiene (HH) and washroom sink drains in ICU rooms after the patients had been discharged. Information was gathered on CPE risk factors, such as recent travel history or hospitalization outside of Canada, endoscopic retrograde cholangiopancreatography procedures, or hemodialysis within the last 12 months. Results: During the surveillance period, 15 non-duplicate CPE isolates were obtained from 14 patients in the ICU. Out of the 14, 10 patients were identified after ICU stays of greater than 72 hours. Klebsiella pneumoniae carbapenemase (KPC) was the most identified carbapenemase, found in five (50%) of isolates, followed by three (30%) New Delhi metallo-β-lactamase, and two (20%) Oxacillinase-48 like carbapenemase. In addition, a total of 33 sink drains underwent testing: 24 were HH sinks, while nine were inpatient washrooms. Among the 24 HH sink drains, nine (37.5%) tested positive for CPE, eight of these sink drains (88.9%) had KPC genes, two (22%) had NDM genes, and one (11%) had VIM genes. Among the HH sink drains contaminated by CPE, three (33.3%) out of these nine shared the same species/gene combination (KPC-Citrobacter freundii) as the CPE-positive patient recently discharged from the room. Conclusion: These findings suggest a potential link between KPC-producing Citrobacter freundii detected in the HH sink drain and a CPE-positive patient. However, the direction of transmission remains unclear. Further research is necessary to analyze the molecular genotyping and validate any potential relatedness among them, in addition, collaborative efforts from the infection prevention and control, microbiology, environmental, and facilities teams are essential to eliminate CPE from HH sink drains.

In developing hygiene strategies, in recent years, the major focus has been on the hands as the key route of infection transmission. However, there is a multitude of lesser-known and underestimated reservoirs for microorganisms which are the triggering sources and vehicles for outbreaks or sporadic cases of infection. Among those are water reservoirs such as sink drains, fixtures, decorative water fountains and waste-water treatment plants, frequently touched textile surfaces such as private curtains in hospitals and laundry, but also transvaginal ultrasound probes, parenteral drug products, and disinfectant wipe dispensers. The review of outbreak reports also reveals Gram-negative and multiple-drug resistant microorganisms to have become an increasingly frequent and severe threat in medical settings. In some instances, the causative organisms are particularly difficult to identify because they are concealed in biofilms or in a state referred to as viable but nonculturable, which eludes conventional culture media-based detection methods. There is an enormous preventative potential in these insights, which has not been fully tapped. New and emerging pathogens, novel pathogen detection methods, and hidden reservoirs of infection should hence be given special consideration when designing the layout of buildings and medical devices, but also when defining the core competencies for medical staff, establishing programmes for patient empowerment and education of the general public, and when implementing protocols for the prevention and control of infections in medical, community and domestic settings.

Background: There is an insufficient understanding of factors that impede nursing students' learning of healthcare-associated infection prevention and control in developing countries. This study aimed to explore current challenges in healthcare-associated infection control and prevention education in the nursing curriculum in two Vietnamese and two Cambodian universities. Methods: Exploratory research was conducted through consultation of education programs and a qualitative study design utilizing interviews and focus group discussions. Data collection was conducted through interviews with university board members and focus group discussions with lecturers and tutors. The data were analyzed by using content analysis methods. Results: The research results indicated that there were three generic themes of challenges in teaching HAIs-PC in nursing education in Vietnam and Cambodia. They were Implementation of healthcare associated infections prevention and control education into nursing curriculum, Positive aspects fostering healthcare associated infections prevention and control learning, Negative aspects hindering healthcare associated infections prevention and control learning. Conclusions: The study results provided evidence of challenges in healthcare associated infections prevention and control education in some Asia higher education institutions. To improve professional safety, universities should pay more attention to developing appropriate teaching methods for healthcare-associated infections prevention and control education to improve students' practice outcomes.

Healthcare Infections Associated with Care and Treatment of Humans and Animals

Background A commercially available foaming disinfectant containing hydrogen peroxide, peracetic acid, and octanoic acid is EPA-registered for biofilm disinfection in sink drains, but recolonization occurs quickly. We evaluated the impact of adding physical removal of bioburden to foaming disinfectant use on bacterial colonization in sink drains. Methods We conducted a longitudinal study in a level-IV neonatal intensive care unit (NICU) at an academic medical center in Baltimore, MD. The NICU has 52 single-patient rooms with sinks with removable drain plug covers. We included 20 unique rooms to investigate the effect of foaming disinfectant alone and coupled with physical removal of biofilm through (1) mechanical cleaning with a brush, and (2) replacement of drain cover (Figure 1). In addition, we sampled 10 room sinks as control (no intervention). Samples were collected from 2 inches below the sink drain and underside of the drain cover using a polyester tripped swab (Puritan ESK environmental sampling kit with neutralizing buffer) at baseline (day 0) and days 1, 3, 5, and 7 post-intervention. Samples were serially diluted, plated on MacConkey II agar (Becton Dickinson), and incubated for 24 hours at 35+2°C. Colony-forming units (CFU) of total gram-negative bacilli (GNB) were calculated. The primary outcome was the difference in GNB burden (mean log CFUs) from baseline at each time point, for each intervention strategy, compared using paired t-test. Results Baseline counts for all groups including control were similar. On day 1, we found significant reductions from baseline for each intervention strategy, with differences from baseline becoming smaller over time. There was no significant change in GNB counts for the control group at any time point (Figure 2, Table 1). Strategies with mechanical cleaning (vs without) performed better for sinks, whereas sink cover change (vs without) resulted in greater log reductions in the cover bioburden through day 7 (Figure 2, Table 1). Conclusion Physical bioburden removal improved the effect of a foaming disinfectant on GNB counts in hospital sink drains. The impact of this strategy on hospital-acquired infections needs to be studied. Disclosures J Kristie Johnson, PhD, D (ABMM), biomerieux: has given presentations/speeches for the company listed above

Background: Carbapenem-resistant Enterobacterales (CRE) are reportable statewide with required isolate submission to the Minnesota Department of Health (MDH) Public Health Laboratory (PHL), where carbapenemase production and mechanism identification is confirmed. MDH reviews all detected carbapenemase-producing organisms (CPOs) for potential transmission. Suspected transmission clusters are assessed for relatedness using whole genome sequencing (WGS). In 2022, increased detection of multiple bacterial genera of Klebsiella pneumoniae carbapenemase (KPC)-CRE occurred at acute care hospital-A, (ACH-A) and in 2023 the increase in KPC-CRE was accompanied by an increase in New Delhi metallo-β-lactamase (NDM)-CRE detection. Methods: MDH partnered with ACH-A to review increased CPO detection. MDH-PHL conducted WGS including multilocus sequence typing (MLST) and single nucleotide polymorphism (SNP) analysis on isolates. WGS suggested clusters of relatedness spanning multiple years and epidemiologic data revealed common room occupancy. Infection prevention and control (IPC) principles were reinforced in cluster areas and audits verified adherence, prompting consideration of an environmental reservoir. An environmental screening plan was developed focusing on sink drains from common rooms. In May 2024, 94 swabs from sink drains were collected and CPO culture-based screening was conducted using selective media followed by molecular testing of bacterial growth by MDH-PHL. Results: There was detection of CPOs from 28 of 94 (29.8%) sink drains. Eight environmental KPC-CRE isolates and one NDM-CRE isolate appeared genetically related to 22 unique patients over a 10-year period (Figure 1). Three sink drain isolates showed genetic similarity to each other, but not to patient isolates. Three CPO clusters, representing 14 patients, had genetically similar isolates without an associated environmental isolate. However, isolates were collected over months to years suggesting an undetected reservoir. In August 2024, ACH-A initiated mitigation strategies to prevent CPO transmission from environmental reservoirs, including modification of sink plumbing, maintaining a splash zone, refraining from disposal of bodily fluids in sinks, optimizing sink hygiene, and monthly screening of inpatients in units with known CPO sink contamination. From August to December 2024, 325 patients were screened with 1.2% of specimens detecting KPC-CRE colonization. Conclusion: Sink drains containing CPOs on multiple hospital units that correlated with patient cases were identified at ACH-A. WGS suggests intermittent transmission of different CPOs over 10 years, and clusters of transmission appear to be related to environmental sources. Strict implementation and adherence to IPC measures, including those that minimize the spread of CPOs from facility premise plumbing, are critical to prevent CPO transmission despite widespread premise plumbing contamination.

To perform a review of the literature on the role of simulation-based training (SBT) in healthcare-associated infection (HAI) prevention and to highlight the importance of SBT as an educational tool in infection prevention. We reviewed English language publications from PubMed to select original articles that utilized SBT as the primary mode of education for infection prevention efforts in acute-care hospitals. Overall, 27 publications utilized SBT as primary mode of education for HAI prevention in acute-care hospitals. Training included the following: hand hygiene in 3 studies (11%), standard precaution in 1 study (4%), disaster preparedness in 4 studies (15%), central-line-associated blood stream infection (CLABSI) prevention in 14 studies (52%), catheter-associated urinary tract infection (CAUTI) prevention in 2 studies (7%), surgical site infection prevention in 2 studies (7%), and ventilatory associated pneumonia prevention in 1 study (4%). SBT improved learner's sense of competence and confidence, increased knowledge and compliance in infection prevention measures, decreased HAI rates, and reduced healthcare costs. SBT can function as a teaching tool in day-to-day infection prevention efforts as well as in disaster preparedness. SBT is underutilized in infection prevention but can serve as a crucial educational tool.

Results from the second Scottish national prevalence survey: the changing epidemiology of healthcare-associated infection in Scotland

Background and purpose: The implementation of healthcareassociated infections (HAIs) prevention and control program in hospitals remains sub-optimal. The present study aims to determine the relationships between nurse’s self-efficacy, hospital’s occupational safety environment, and the availability of facilities, with the compliance on HAIs prevention and control in hospital inpatient care units. Methods: Cross-sectional survey was conducted with 128 nurses selected using systematic random sampling at Buleleng District Hospital’s inpatient care units. Data collection was conducted in March 2018 using self-administered questionnaires. The questionnaire consisted of five sections including characteristics of respondents, HAIs prevention and control practices, self-efficacy, occupational safety environment and the availability of facilities. Bivariate analysis was conducted to calculate the Pearson correlation coefficients between variables. Multivariate analysis was performed with multiple linear regressions to examine self-efficacy, occupational safety environment and availability of facilities as predictors of the compliance on HAIs prevention and control. Results: The study shows that 56.2% of nurses reported good compliance on HAIs prevention and control practices. Bivariate analysis shows a significant correlation between HAIs prevention and control compliance scores and self-efficacy (r=0.45; p=0.00), occupational safety environment (r=0.53; p=0.00), and the availability of facilities (r=0.65; p=0.00). Multivariate analysis shows that the availability of facilities is a significant predictor of HAIs prevention and control compliance (β=0.49; p<0.01) while self-efficacy and the occupational safety environment are also found to be significant predictors, although with lower standardized coefficients: β=0.16 (p=0.03) and β=0.17 (p=0.04), respectively. Conclusion: The significant predictors of compliance on HAIs prevention and control are availability of facilities, self efficacy and hospital’s occupational safety environment. This study highlights the importance of optimizing the availability of facilities, improving the occupational safety environment, and enhancing nurses’ self-efficacy in order to reduce the incidence of HAIs in hospitals.

BackgroundHealthcare-associated infections in long-term care are associated with substantial morbidity and mortality. While infection prevention and control (IPC) guidelines are well-defined in the acute care setting, evidence of effectiveness for long-term care facilities (LTCF) is missing. We therefore performed a systematic literature review to examine the effect of IPC measures in the long-term care setting.MethodsWe systematically searched PubMed and Cochrane libraries for articles evaluating the effect of IPC measures in the LTCF setting since 2017, as earlier reviews on this topic covered the timeframe up to this date. Cross-referenced studies from identified articles and from mentioned earlier reviews were also evaluated. We included randomized-controlled trials, quasi-experimental, observational studies, and outbreak reports. The included studies were analyzed regarding study design, type of intervention, description of intervention, outcomes and quality. We distinguished between non-outbreak and outbreak settings.ResultsWe included 74 studies, 34 (46%) in the non-outbreak setting and 40 (54%) in the outbreak setting. The most commonly studied interventions in the non-outbreak setting included the effect of hand hygiene (N = 10), oral hygiene (N = 6), antimicrobial stewardship (N = 4), vaccination of residents (N = 3), education (N = 2) as well as IPC bundles (N = 7). All but one study assessing hand hygiene interventions reported a reduction of infection rates. Further successful interventions were oral hygiene (N = 6) and vaccination of residents (N = 3). In outbreak settings, studies mostly focused on the effects of IPC bundles (N = 24) or mass testing (N = 11). In most of the studies evaluating an IPC bundle, containment of the outbreak was reported. Overall, only four articles (5.4%) were rated as high quality.ConclusionIn the non-outbreak setting in LTCF, especially hand hygiene and oral hygiene have a beneficial effect on infection rates. In contrast, IPC bundles, as well as mass testing seem to be promising in an outbreak setting.

Third-generation cephalosporin-resistant Enterobacterales is a major threat for newborns in neonatal intensive care units (NICUs). The route of acquisition in a non-outbreak setting should be investigated to implement adequate infection prevention measures. To identify risk factors for colonization with and to investigate the transmission pattern of third-generation cephalosporin-resistant Enterobacterales in a NICU setting. This monocentric observational cohort study in a tertiary NICU in Heidelberg, Germany, enrolled all hospitalized neonates screened for cephalosporin-resistant Enterobacterales. Data were collected from 1 January 2018 to 31 December 2021. Weekly screening by rectal swabs for colonization with third-generation cephalosporin-resistant Enterobacterales was performed for all newborns until discharge. Whole-genome sequencing was performed for molecular characterization and transmission analysis. In total, 1,287 newborns were enrolled. The median length of stay was 20 (range 1-250) days. Eighy-eight infants (6.8%) were colonized with third-generation cephalosporin-resistant Enterobacterales. Low birth weight [<1500 g (adjusted odds ratio, 5.1; 95% CI 2.2-11.5; P < 0.001)] and longer hospitalization [per 30 days (adjusted odds ratio, 1.7; 95% CI 1.5-2.0; P < 0.001)] were associated with colonization or infection with drug-resistant Enterobacterales in a multivariate analysis. Enterobacter cloacae complex was the most prevalent third-generation cephalosporin-resistant Enterobacterales detected, 64.8% (59 of 91). Whole-genome sequencing, performed for the available 85 of 91 isolates, indicated 12 transmission clusters involving 37 patients. This cohort study suggests that transmissions of third-generation cephalosporin-resistant Enterobacterales in newborns occur frequently in a non-outbreak NICU setting, highlighting the importance of surveillance and preventive measures in this vulnerable patient group. IMPORTANCE Preterm newborns are prone to infections. Therefore, infection prevention should be prioritized in this vulnerable patient group. However, outbreaks involving drug-resistant bacteria, such as third-generation resistant Enterobacterales, are often reported. Our study aims to investigate transmission and risk factors for acquiring third-generation cephalosporin-resistant Enterobacterales in a non-outbreak NICU setting. Our data indicated that premature birth and low birth weight are significant risk factors for colonization/infection with third-generation cephalosporin-resistant Enterobacterales. Furthermore, we could identify putative transmission clusters by whole-genome sequencing, highlighting the importance of preemptive measures to prevent infections in this patient collective.

Background: There is an insufficient understanding of factors that impede nursing students’ learning of healthcare-associated infection prevention and control in developing countries. This study aimed to explore current challenges in healthcare-associated infection control and prevention education in the nursing curriculum in two Vietnamese and two Cambodian universities. Methods: Exploratory research was conducted through consultation of education programs and a qualitative study design utilizing interviews and focus group discussions. Data collection was conducted through interviews with university board members and focus group discussions with lecturers and tutors. The data were analyzed by using content analysis methods. Results: The research results indicated that there were three generic themes of challenges in teaching HAIs-PC in nursing education in Vietnam and Cambodia. They were Implementation of healthcare associated infections prevention and control education into nursing curriculum, Positive aspects fostering healthcare associated infections prevention and control learning, Negative aspects hindering healthcare associated infections prevention and control learning. Conclusions: The study results provided evidence of challenges in healthcare associated infections prevention and control education in some Asia higher education institutions. To improve professional safety, universities should pay more attention to developing appropriate teaching methods for healthcare-associated infections prevention and control education to improve students’ practice outcomes.