Transmission Of Healthcare-associated Infections Research Articles

Innovative Methods of Hospital Disinfection in Prevention of Healthcare-Associated Infections

The purpose of this review is to give the reader an update on recent studies and developments regarding the hospital environment role in transmission of healthcare-associated infections (HAIs), and novel strategies to obtain a cleaner, safer patient environment. Hospital patient rooms are increasingly recognized as a reservoir of multi-drug-resistant organisms that contribute to HAIs. In simulated environments, surfaces can easily be adequately disinfected of pathogenic bacteria. However, translation into real healthcare settings has been less reliable and efficacious, with barriers to implementation of best practices. In this review, we describe and compare new and evolving technologies for enhancing room disinfection, such as UV-C, hydrogen peroxide vapor, ozone, and chlorine. We also review recent studies examining antimicrobial surfaces such as copper and silver and introduce a novel transdisciplinary human factors, systems engineering, and infection prevention approach to improve manual room cleaning. We highlight outstanding questions, including additional benefit of no touch technology in a human factors-optimized manual cleaning setting, and cost-effectiveness of optimized manual cleaning vs additional of no touch technology. There are evolving technologies and strategies to enhance patient room cleaning and decrease risk of HAI transmission. It is important for the infection prevention community to keep up to date with, and understand the implications of, these developments so as to best inform hospital HAI reduction strategy.

The Emergency Medical Service Microbiome.

Emergency medical services (EMS) personnel are an integral component of the health care framework and function to transport patients from various locations to and between care facilities. In addition to physical injury, EMS personnel are expected to be at high risk to acquire and transmit health care-associated infections (HAIs) in the workplace. However, currently, little is known about EMS biosafety risk factors and the epidemiological contribution of EMS to pathogen transmission within and outside the health care sector. Health care facility microbiomes contain diverse bacterial, fungal, and viral pathogens that cause over 1.7 million HAIs each year in the United States alone. While hospital microbiomes have been relatively well studied, there is scant information about EMS infrastructure and equipment microbiomes or the role(s) they play in HAI transmission between health care facilities. We review recent literature investigating the microbiome of ambulances and other EMS service facilities which consistently identify antibiotic-resistant pathogens causing HAIs, including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus, and Klebsiella pneumoniae Our review provides evidence that EMS microbiomes are dynamic and important pathogen reservoirs, and it underscores the need for more widespread and in-depth microbiome studies to elucidate patterns of pathogen transmission. We discuss emerging DNA sequencing technologies and other methods that can be applied to characterize and mitigate EMS biosafety risks in the future. Understanding the complex interplay between EMS and hospital microbiomes will provide key insights into pathogen transmission mechanisms and identify strategies to minimize HAIs and community infection.

A comparative study of hand hygiene and alcohol-based hand rub use among Irish nursing and medical students

BackgroundIn Ireland, the setting for this study, the national prevalence rate of health care-associated infection (HCAI) in acute-care facilities is 5.2%. Hand hygiene and in particular hand rubbing using alcohol-based hand rub (ABHR) is highly efficacious in preventing HCAI transmission. Yet, compliance among healthcare professionals is sub-optimal. Less is known about the practices of nursing and medical students and no study comparing practices among these groups in Ireland was found. Hence, the aim of this study was to provide insight into the current hand hygiene and hand rubbing practices of nursing and medical students in Ireland and, by doing so, contribute to the broader understanding of this topic. MethodsThis observational study employed a cross-sectional, self-reported design. An electronically administered questionnaire was sent to all nursing and medical students from one university. Data were analysed using appropriate software. ResultsThe response rate was 37% (323/872). Higher compliance with the World Health Organisation ‘my five moments for hand hygiene’ model was reported among nursing students (NS) than medical students (MS), with scope for improvement in both disciplines identified. Hand hygiene compliance was highest after body fluid exposure (99.5% NS, 91% MS) and lowest after touching a patient's surroundings (61.5% NS, 57.5% MS). Attitudes towards hand rubbing were largely positive in both disciplines. 16% of NS were not aware of the clinical contraindications to ABHR use, compared to 45% of MS. 9% of NS did not know when to use soap and water and when to use ABHR, compared to 36% of MS. In contrast, more medical students (46%) than nursing students (22%) were routinely using alcohol-based hand rub for decontamination of hands as recommended. ConclusionsResults suggest scope to review current hand hygiene curricula focusing on the knowledge gaps, the practice deficits and the barriers to ABHR usage identified.

Comparative Antimicrobial Efficacy of Two Hand Sanitizers in Intensive Care Units Common Areas: A Randomized, Controlled Trial.

OBJECTIVE Contaminated hands of healthcare workers (HCWs) are an important source of transmission of healthcare-associated infections. Alcohol-based hand sanitizers, while effective, do not provide sustained antimicrobial activity. The objective of this study was to compare the immediate and persistent activity of 2 hand hygiene products (ethanol [61% w/v] plus chlorhexidine gluconate [CHG; 1.0% solution] and ethanol only [70% v/v]) when used in an intensive care unit (ICU). DESIGN Prospective, randomized, double-blinded, crossover study SETTING Three ICUs at a large teaching hospital PARTICIPANTS In total, 51 HCWs involved in direct patient care were enrolled in and completed the study. METHODS All HCWs were randomized 1:1 to either product. Hand prints were obtained immediately after the product was applied and again after spending 4-7 minutes in the ICU common areas prior to entering a patient room or leaving the area. The numbers of aerobic colony-forming units (CFU) were compared for the 2 groups after log transformation. Each participant tested the alternative product after a 3-day washout period. RESULTS On bare hands, use of ethanol plus CHG was associated with significantly lower recovery of aerobic CFU, both immediately after use (0.27 ± 0.05 and 0.88 ± 0.08 log10 CFU; P = .035) and after spending time in ICU common areas (1.81 ± 0.07 and 2.17 ± 0.05 log10 CFU; P<.0001). Both the antiseptics were well tolerated by HCWs. CONCLUSIONS In comparison to the ethanol-only product, the ethanol plus CHG sanitizer was associated with significantly lower aerobic bacterial counts on hands of HCWs, both immediately after use and after spending time in ICU common areas. CLINICAL TRIAL IDENTIFIER Clinicaltrials.gov identifier NCT02258412 Infect Control Hosp Epidemiol 2018;39:267-271.

Environmental Cleaning in Resource-Limited Settings.

Opinion statementPurpose of reviewEnvironmental surfaces in healthcare facilities, particularly in a patient room, are a critical pathway for healthcare-associated pathogen transmission. Despite well-established guides and recommendations regarding environmental surface cleaning and disinfection, there are several challenges in resource-limited settings. This viewpoint article will discuss the practice of environmental cleaning in resource-limited settings including challenges and relationship between environment and healthcare-associated infections in this setting and outlines pre-requisites to overcome these challenges.Recent findingsDespite several barriers and challenges, environmental cleaning is a crucial component to help reduce transmission of healthcare-associated infections and multi-drug-resistant pathogens as well as emerging infectious disease-associated pathogens in resource-limited settings. However, there is a need to develop a multi-modal strategy together with a mechanism for monitor and feedback to improve the practices of environmental cleaning in resource-limited settings.SummaryAdditional researches on the barriers and implementation gaps and the role of collaborative network as well as how to apply technology would provide significant insights on the practices of environmental cleaning in resource-limited settings.

Mathematical models of infection transmission in healthcare settings: recent advances from the use of network structured data.

Mathematical modeling approaches have brought important contributions to the study of pathogen spread in healthcare settings over the last 20 years. Here, we conduct a comprehensive systematic review of mathematical models of disease transmission in healthcare settings and assess the application of contact and patient transfer network data over time and their impact on our understanding of transmission dynamics of infections. Recently, with the increasing availability of data on the structure of interindividual and interinstitution networks, models incorporating this type of information have been proposed, with the aim of providing more realistic predictions of disease transmission in healthcare settings. Models incorporating realistic data on individual or facility networks often remain limited to a few settings and a few pathogens (mostly methicillin-resistant Staphylococcus aureus). To respond to the objectives of creating improved infection prevention and control measures and better understanding of healthcare-associated infections transmission dynamics, further innovations in data collection and parameter estimation in modeling is required.

Long-acting water-stable organosilane agent and its sustained effect on reducing microbial load in an intensive care unit

Contaminated hospital surfaces contribute significantly to the transmission of health care-associated infections. Although disinfectants reduce bioburden by up to 99%, bacterial growth can rebound within hours to precleaning levels. We tested the effectiveness of an innovative, long-acting water-stable organosilane (WSO) to achieve sustained decreases in bioburden on hard surfaces. A 5-month prospective, randomized, double-blind controlled study was performed. Eighteen intensive care unit rooms were randomly divided into placebo or treatment groups. Hard surfaces in all rooms were cleaned using the same protocol, except the placebo surfaces were cleaned with an inert saline solution and the treatment surfaces were treated with the WSO. Binomial regression with repeated measures were used to assess mean reductions in total bioburden as measured by colony forming units. The placebo resulted in average reductions in total colony forming units of 35% to 40% (relative risk reduction [RRR], 0.65; P < .01) and the WSO group averaged reductions of colony forming units by 66% to 99% (RRR, 0.55; P < .001). Total Staphylococcus aureus increased among the placebo rooms 30% (RRR, 0.69; P < .001), whereas in treatment rooms there was a reduction of 50%-60% (RRR, 0.57; P < .01). Although both sets of rooms saw reductions in bioburden or colony forming units, application of the WSO resulted in larger reductions. There was also greater variability in reductions in the placebo arm. This is the first randomized, double-blind controlled study of an innovative WSO on high-touch hard surfaces at risk for high bioburdens. Sustained reductions of bioburden with the monthly application of this unique WSO may be associated with significant reductions in the risk of health care-associated infections.

Investigating the use of an electronic hand hygiene monitoring and prompt device: influence and acceptability.

Hand hygiene (HH) prevents the transmission of healthcare-associated infections. Electronic HH monitoring and prompt devices have been developed to overcome problems with monitoring HH and to improve compliance. Devices monitor room entry and exit and soap use through communication between ceiling sensors and badges worn by practitioners and the badges sense alcohol rub. To investigate (1) the impact of devices on HH compliance, (2) how devices influence behaviour and (3) the experience and opinions of practitioners on the use devices. HH compliance was monitored (before, during and after system installation) by observations and alcohol rub usage. Compliance during installation was also monitored by the device. Healthcare practitioner interviews (n = 12) explored how the device influenced behaviour and experiences and opinions of wearing the device. HH compliance improved during the period the device was installed. Practitioners reported the device increased their awareness, enhancing their empathy for patients and encouraged patients and colleagues to prompt when HH was needed. Practitioners' reported better HH, gaming the system and feelings of irritation. HH prompt and monitoring systems seem to improve compliance but improvements may be undermined by practitioner irritation and system gaming.

Transmission of health care-associated infections from roommates and prior room occupants: a systematic review.

Pathogens that cause health care-associated infections (HAIs) are known to survive on surfaces and equipment in health care environments despite routine cleaning. As a result, the infection status of prior room occupants and roommates may play a role in HAI transmission. We performed a systematic review of the literature evaluating the association between patients’ exposure to infected/colonized hospital roommates or prior room occupants and their risk of infection/colonization with the same organism. A PubMed search for English articles published in 1990–2014 yielded 330 studies, which were screened by three reviewers. Eighteen articles met our inclusion criteria. Multiple studies reported positive associations between infection and exposure to roommates with influenza and group A streptococcus, but no associations were found for Clostridium difficile, methicillin-resistant Staphylococcus aureus, Cryptosporidium parvum, or Pseudomonas cepacia; findings were mixed for vancomycin-resistant enterococci (VRE). Positive associations were found between infection/colonization and exposure to rooms previously occupied by patients with Pseudomonas aeruginosa and Acinetobacter baumannii, but no associations were found for resistant Gram-negative organisms; findings were mixed for C. difficile, methicillin-resistant S. aureus, and VRE. Although the majority of studies suggest a link between exposure to infected/colonized roommates and prior room occupants, methodological improvements such as increasing the statistical power and conducting universal screening for colonization would provide more definitive evidence needed to establish causality.

Self-reported behaviors and perceptions of Australian paramedics in relation to hand hygiene and gloving practices in paramedic-led health care

Noncompliance with recommended hand hygiene and gloving practices by workers in the emergency medical services may contribute to the transmission of health care-associated infections and lead to poor patient outcomes. The aim of this study was to explore the self-reported behaviors and perceptions of Australian paramedics in relation to their hand hygiene and gloving practices in paramedic-led health care. A national online survey (n = 417; 17% response rate) and 2 semistructured focus groups (6 per group) were conducted with members of Paramedics Australasia. Although most of the study participants perceived hand hygiene and gloving to be important, the findings suggest poor compliance with both practices, particularly during emergency cases. All participants reported wearing gloves throughout a clinical case, changing them either at the completion of patient care or when visibly soiled or broken. Hand hygiene was missed at defined moments during patient care, possibly from the misuse of gloves. Paramedic hand hygiene and gloving practices require substantial improvement to lower potential transmission of pathogens and improve patient safety and clinical care. Further research is recommended to explore how to alleviate the barriers to performing in-field hand hygiene and the misuse of gloves during paramedic-led health care.

Factors influencing compliance to the infection control precautions among nurses and physicians in Jordan: A cross-sectional study.

Adherence to infection control precautions (ICP) is important to reduce the transmission of healthcare-associated infections (HAIs). To determine nurses and physician's knowledge, attitude and compliance to ICPs and factors associated with reported compliance. A cross-sectional survey of nurses and physicians recruited from three hospitals at three different healthcare sectors in Jordan. Three instruments were used to assess knowledge, attitudes and compliance to ICPs. A total of 211 professionals completed the survey: 155 nurses and 56 physicians. Both groups had low knowledge scores for ICP but a high positive attitude. Although both groups had high reported compliance scores, nurses scores were higher (P = 0.04). Participants from the private hospital had higher knowledge and compliance scores. Length of experience, knowledge and attitude were significant predictors of reported compliance to ICPs. Despite poor knowledge, Jordanian healthcare professionals reported high scores for positive attitudes and compliance with IPCs. Clinical training programmes are required to enhance knowledge and understanding of IPCs.

Portable Medical Equipment: A Network Analysis Showing the Potential Missing Link in Infection Prevention Practices

Background High-touch surfaces in the hospital environment, such as bed rails, tray tables, and supply carts, are considered important in the epidemiology of transmission of healthcare-associated infections (HAIs). If not removed adequately, pathogens can remain viable on fomites for months, serving as a source of transmission on a number of susceptible patients. An additional source of transmission for which there is limited available research is portable medical equipment (PME). The purpose of this study was to investigate the patterns and sequence of touch events among health care workers, patients, surfaces, and equipment in the hospital environment, to better inform our understanding of potential infection transmission pathways.Methods This observational study was conducted at a 120-bed Veterans Affairs (VA) hospital in Temple, TX, on six inpatient units. Continuous 24-hour observation was performed separately on each unit by two research team members observing for 8-hour sessions. Observations of healthcare workers’ (HCW) touches of surfaces, patient, and objects were recorded in sequence. The observations of touches were recorded as a sequence of events analyzed with sequence analysis software and visually represented by network plots.ResultsThe sequence of touches are visualized in the network plots. The sequence analysis revealed the top 20 subsequences.Conclusion The network plots revealed that almost all of the items touched were connected to at least a few other items in a sequence of touches. The patient, the most commonly touched item, had a potential for contamination from other surfaces as well as a potential for transmitting pathogens to other surfaces. Thus most items in the room have the potential to be contaminated if indeed the patient is considered the primary source of the contamination, and the patient has the potential be become infected if the other objects are consider the source. Our results illustrating the interconnectedness of touch sequences between HCW and PME are consistent with the study by Hayden et al. that showed that HCW’s hands were contaminated almost as much by touching only the environment in the patient room as when they touched both the patient and environment.Disclosures C. Jinadatha, NIH: Grant Investigator, Grant recipient. C. Dale, NIH: Grant Investigator, Grant recipient and Research grant. R. Whitworth, NIH: Grant Investigator, Grant recipient. M. Stibich, NIH: Grant Investigator, Grant recipient.

Infant isolation and cohorting for preventing or reducing transmission of healthcare-associated infections in neonatal units

Infant isolation and cohorting for preventing or reducing transmission of healthcare-associated infections in neonatal units

Evaluating the effectiveness of ultraviolet-C lamps for reducing keyboard contamination in the intensive care unit: A longitudinal analysis.

Ultraviolet (UV) spectrum light for decontamination of patient care areas is an effective way to reduce transmission of infectious pathogens. Our purpose was to investigate the efficacy of an automated UV-C device to eliminate bioburden on hospital computer keyboards. The study took place at an academic hospital in Chicago, Illinois. Baseline cultures were obtained from keyboards in intensive care units. Automated UV-C lamps were installed over keyboards and mice of those computers. The lamps were tested at varying cycle lengths to determine shortest effective cycles. Delay after use and prior to cycle initiation was varied to minimize cycle interruptions. Finally, 218 postinstallation samples were analyzed. Of 203 baseline samples, 193 (95.1%) were positive for bacteria, with a median of 120 colony forming units (CFU) per keyboard. There were numerous bacteria linked to health care-associated infections (HAIs), including Staphylococcus, Streptococcus, Enterococcus, Pseudomonas, Pasteurella, Klebsiella, Acinetobacter, and Enterobacter. Of the 193 keyboards, 25 (12.3%) had gram-negative species. Of 218 postinstallation samples, 205 (94%) were sterile. Of the 13 that showed bacterial growth, 6 produced a single CFU. Comparison of pre- and post-UV decontamination median CFU values (120 and 0, respectively) revealed a >99% reduction in bacteria. The UV lamp effectively decontaminates keyboards with minimal interruption and low UV exposure. Further studies are required to determine reduction of HAI transmission with use of these devices.

Summary of Evidence-Based Practices for Bloodstream Infection Prevention Across the Health Care Continuum of Care for Vascular Access Clinicians: Addressing the 3 Common Sources of Health Care-Associated Infection Transmission

Infection prevention and control is a core element of patient safety and in the reduction of central line-associated bloodstream infections. These deadly infections can cause a mortality rate of approximately 12%-25% in inpatient populations. Bloodstream infections can in many cases be prevented through the adoption of evidence-based standards from organizations such as the Centers for Disease Control and Prevention and the Association for Vascular Access. Vascular access professionals play a critical role in infection prevention in patient care by practicing frequent hand hygiene, maintaining a clean and sanitary clinical environment of care, and performing proper skin antisepsis before the insertion of a vascular access catheter. Each of these interventions contributes to the overall goal of eliminating central line-associated bloodstream infections in these very vulnerable patients.

Impact of a Probiotic-Based Cleaning Intervention on the Microbiota Ecosystem of the Hospital Surfaces: Focus on the Resistome Remodulation.

BackgroundContamination of hospital surfaces by clinically-relevant pathogens represents a major concern in healthcare facilities, due to its impact on transmission of healthcare-associated infections (HAIs) and to the growing drug resistance of HAI-associated pathogens. Routinely used chemical disinfectants show limitations in controlling pathogen contamination, due to their inefficacy in preventing recontamination and selection of resistant strains. Recently we observed that an innovative approach, based on a cleanser added with spores of non-pathogenic probiotic Bacilli, was effective in stably counteracting the growth of several pathogens contaminating hospital surfaces.MethodsHere, we wanted to study the impact of the Bacillus-based cleanser on the drug-resistance features of the healthcare pathogens population. In parallel, the ability of cleanser-derived Bacilli to infect hospitalized patients was also investigated.ResultsCollected data showed that Bacilli spores can germinate on dry inanimate surfaces, generating the bacterial vegetative forms which counteract the growth of pathogens and effectively substitute for them on treated surfaces. Strikingly, this procedure did not select resistant species, but conversely induced an evident decrease of antibiotic resistance genes in the contaminating microbial population. Also importantly, all the six HAI-positive patients hosted in the treated areas resulted negative for probiotic Bacilli, thus adding evidences to their safety-to-use.ConclusionsThese results indicate that this probiotic-based procedure is active not only in controlling surface microbial contamination but also in lowering drug-resistant species, suggesting that it may have relevant clinical and therapeutical implications for the management of HAIs.

Role of environmental cleanliness and decontamination in care homes.

While it is widely accepted that the environment has an important role in transmission of healthcare-associated infections, there has been a paucity of empirical investigation in this area to date, and the majority of published literature relates to acute settings. People living in care homes come into contact with a communally used environment and communally used equipment daily. Equipment may include hoists, hoist slings, clinical monitoring equipment, commodes and shower chairs. In care homes, primary responsibility for decontamination lies with the healthcare team, most of whom are not nurses. The challenge for nurses working in care homes is their accountability for the provision of safe and effective care.

Hand Hygiene in Haemodialysis Units

Healthcare-associated infections are a major risk to patient safety. Infection is the first cause of hospitalisation and the second most common cause of mortality among haemodialysis (HD) patients. HD patients, as well as the dialysis staff, are vulnerable to contracting healthcare-associated infections due to frequent and prolonged exposures to many possible contaminants in the dialysis environment. The extracorporeal nature of the therapy, the associated common environmental conditions, and the immune compromised status of HD patients are major predisposing factors. HD patients are exposed to different types of infections which include bloodstream infections and localized infections of the vascular access, blood-borne infections with hepatitis B virus, hepatitis C virus, and/or human immunodeficiency virus, and airborne infections. Sources of infections include contaminated water, equipment, environmental surfaces, and infected patients. The evident increased potential for transmission of infections in the HD settings led to the creation and implementation of specific and stricter infection prevention and control measures in addition to the usual standard precautions. Contaminated hands of healthcare workers are among the most common modes of transmission of healthcare-associated infections. Hand hygiene is singled out as the most important infection prevention intervention. Hand hygiene compliance can be improved by continuous education and monitoring, providing a sufficient number of sinks with soap dispensers, paper towels, hand lotions and alcohol-based hand rub placed at each patient station, and regular feedback of surveillance results. Education and training and full awareness of infection control policies and procedures should be provided to all Healthcare workers and to be repeated regularly. The patient and/or caregiver should also be educated on hand hygiene and the care of new vascular access.

Transmission of Healthcare-Associated Infections From Roommates and Prior Room Occupants: A Systematic Review

Transmission of Healthcare-Associated Infections From Roommates and Prior Room Occupants: A Systematic Review

The Importance of the Clinical Environment in the Transmission of Health Care-Associated Infections

Collaboration is a critical component in the prevention of health care-associated infections (HAIs) in today’s health care environment. Now more than ever, a clean and sanitary patient environment is being measured as a component of the infection prevention and control process. In addition, outcome measures such as patient satisfaction and the cleanliness of the environment are common metrics in this era of continual health care reform. Payers such as the Centers for Medicare and Medicaid Services correlate hospital reimbursement with many of these measures and metrics, resulting in financial effects low-performing facilities. The cleanliness of medical equipment such as a portable ultrasound machines, patient care surfaces, and environment surfaces are all included; thus, an impeccably clean environment is a shared goal between environmental services workers and vascular access professionals. Patients, visitors, and health care providers routinely contaminate health care environments through daily activities, and this can increase the risk for infection transmission. Transmission can result from contact with either contaminated hands or environment surfaces, and also a patient’s own skin flora. One of the most critical interventions that can be routinely performed to decrease the risk for crosstransmission and development of HAIs is routine cleaning and disinfection of the environment. This includes both medical equipment and environment surfaces. High-touch items, such as those used between patients regularly, should be disinfected between each single use to minimize the risk for contamination. 1