Yves Chartier Memorial Lecture during ICAN 2014 in Harare, Zimbabwe: My view on environment

1. Environment
and
HAI
04-­‐11-­‐14
I have absolutely no knowledge of..
environmental or healthcare..
waste management.!
Andreas
Voss
Radboud
UMC
&
CWZ
Nijmegen
The
Netherlands
¤
Robert
Weinstein
esFmated
that
the
source
of
pathogens
causing
a
healthcare-­‐associated
infecFon
in
the
intensive
care
unit
was
as
follows:
²
paFents’
endogenous
flora,
40%–60%;
²
incl.
anFbioFc-­‐driven
changes
in
flora;
²
cross
infecFon
via
the
hands
of
personnel,
20%–40%;
²
other
(incl.
environment):
20%.
modified
from
Wenzel
and
Edmond
ICAN
2014
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2. Environment
and
HAI
04-­‐11-­‐14
PREVENT
everything
MRSA
ESBL
C.dif
&
Co
CRE
…..
ICAN
2014
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3. Environment
and
HAI
04-­‐11-­‐14
Adapted
from
O^er
et
al
ICHE
july
2011,
vol.
32,
no.
7
Innate
surfaces
Water
HCWs
&
pa?ents
Air
Hematology
OperaFng
room
Coming
here
Airborne
isolaFon
or type
ICAN
2014
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4. Environment
and
HAI
04-­‐11-­‐14
¤ 63
surgical
departments
parFcipaFng
in
KISS
¤ >99.000
operaFons
¤ Turbulent
+
HEPA
versus
laminar
airflow
+
HEPA
¤ MulFvariate
analyis
to
comtrol
for
other
factors
influencing
outcome
(SSI)
Brandt et al, Ann Surg 2008; 248:695-700.
Significant
ns
ns
ns
ns
ns
Brandt et al, Ann Surg 2008; 248:695-700.
Follow-­‐up
study
taking
in
account
the
size
of
the
LAF
plenum
shows
no
difference
in
outcome
Brandt et al, Ann Surg 2008; 248:695-700.
¤
Mycobacteria
&
endoscope
reprocessing
¤
Legionella
and
aerosols
¤
Nonfermenters
(especially
Pseudo-­‐
monas
&
Acinetobacter)
in
sinks
&
venFlators
¤
Molds
in
hematology
units
ICAN
2014
4

5. Environment
and
HAI
04-­‐11-­‐14
Villegas
et
al
ICHE
2003;24:284-­‐95
Thus,
what
is
all
the
fuzz
about?
Weber
et
al.
Am
J
Infect
Control
2010;38:S25-­‐33
ICAN
2014
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6. Environment
and
HAI
04-­‐11-­‐14
Kramer
et
al.
BMC
Infect
Dis
2006;6:130
Kramer
et
al.
BMC
Infect
Dis
2006;6:130
Kramer
et
al.
BMC
Infect
Dis
2006;6:130
Environment
is
generally
<10
organisms
per
cm2
C.
difficile
,
VRE,
MRSA
103
to
109
CFUs/g
in
stool
Norovirus
1012
parFcles/g
¤ The
infecFous
dose
for
most
environmentally
associated
nosocomial
pathogens
appears
to
be
low.
²
Less
than
15
S.
aureus
cells
were
sufficient
to
cause
infecFon
in
experimental
lesions,
² Less
than
1
CFU/cm2
was
sufficient
to
cause
C.
difficile
disease
in
mice
² A
single
norovirus
parFcle
is
thought
to
have
the
capacity
to
cause
infecFon
O^er
et
al
ICHE
july
2011,
vol.
32,
no.
7
¤ The
surface
environment
in
rooms
of
colonized
or
infected
paFents
is
frequently
contaminated
with
the
pathogen.
¤ Contact
with
hospital
room
surfaces
or
medical
equipment
by
healthcare
personnel
frequently
leads
to
contaminaFon
of
hands
and/or
gloves.
Weber
&
ICHE
may
2013,
vol.
34,
no.
5
ICAN
2014
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7. Environment
and
HAI
04-­‐11-­‐14
SFefel
et
al
ICHE
2011:32:185-­‐87
Bonten
et
al.
Lancet
1996;348:1615-­‐19
Bobulsky
et
al.
CID
2008;46:447-­‐50
Skin
(orange),
gloves
(blue)
¤ Improved
environmental
cleaning
has
led
to
reduced
risk
of
VRE
and
C.
difficile
transmission.
¤ Admission
to
a
room
previously
occupied
by
a
paFent
with
MRSA,
VRE,
Acinetobacter,
or
C.
difficile
increases
the
risk
for
the
subsequent
paFent
admi^ed
to
the
room
to
acquire
the
pathogen
Weber
&
ICHE
may
2013,
vol.
34,
no.
5
O^er
et
al.
AJIC
2013;41:56
Huslage
et
al.
Infect
Control
Hosp
Epidemiol
2010;
31(8):850-­‐853
ICAN
2014
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8. Environment
and
HAI
04-­‐11-­‐14
Obviously
all
should
be
clean,
but
high-­‐touch
really
needs
to
be!
Huslage
et
al.
Infect
Control
Hosp
Epidemiol
2010;
31(8):850-­‐853
C.
difficile
Eckstein
et
al.
BMC
Infect
Dis
June
2007
Eckstein
et
al.
BMC
Infect
Dis
June
2007
VRE
Eckstein
et
al.
BMC
Infect
Dis
June
2007
ICAN
2014
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9. Environment
and
HAI
04-­‐11-­‐14
Boyce
et
al.
ICHE
2008;29:723
Copper a day -
Keeps MRSA away
Noyce
et
al.
J
Hosp
Infect
2006;63:289-­‐297
¤
MSDS
Poly
spray
(silicone
quaternary
amine)
¤
8
surfaces
²
sink,
call
bu^on,
bedside
table,
monitor,
telephone,
supply
cart,
door
handle,
floor
¤
Results:
² No
significant
effect
on
environmental
contaminaFon
Thom
et
al.
Infect
Control
Hosp
Epidemiol
2014;35:1060-­‐62
Thom
et
al.
Infect
Control
Hosp
Epidemiol
2014;35:1060-­‐62
ICAN
2014
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10. Environment
and
HAI
04-­‐11-­‐14
¤
Problem
adherence?
¤
Love
the
concept
of
changing
the
surface
¤
Studies
with
copper,
silver
silica,
Biosafe
HM
4100
(polymer)
embedded
in
polyurethane,
light-­‐acFvated
anFmicrobials,
…
have
worked
before
Thom
et
al.
Infect
Control
Hosp
Epidemiol
2014;35:1060-­‐62
Freeman
et
al.
AnFmicrob
Resistance
Infect
Control
2014;3:5
¤
We
systemaFcally
sampled
8
surfaces
in
the
rooms
and
bathrooms
of
adult
paFents
colonized
or
infected
with
ESBL-­‐EC
or
ESBL-­‐KP
throughout
their
hospital
stay.
¤
Environmental
contaminaFon
was
defined
as
recovery
of
an
ESBL-­‐producing
organism
matching
the
source
paFent’s
isolate
Rooms
of
paFents
with
ESBL-­‐KP
have
substanFally
higher
contaminaFon
rates
than
those
with
ESBL-­‐EC.
This
finding
may
help
explain
the
apparently
higher
transmissibility
of
ESBL-­‐KP
in
the
hospital
serng
Freeman
et
al.
AnFmicrobial
Resistance
and
InfecFon
Control
2014,
3:5
Freeman
et
al.
AnFmicrobial
Resistance
and
InfecFon
Control
2014,
3:5
ICAN
2014
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11. Environment
and
HAI
04-­‐11-­‐14
¤ Reusable
Fssue
dispensers
with
different
surface
disinfectants
were
randomly
collected
from
healthcare
…
it
faciliis
not
Fes.
about
the
details
of
this
66
dispensers
paper,
but
the
point
¤ “helpful
containing
parts
of
the
disinfectant
that
even
environment”
soluFons
with
surface-­‐may
acbe
Fve
a
source
ingredients
for
infecFwere
ons
collected
in
15
healthcare
faciliFes.
28
dispensers
from
nine
healthcare
faciliFes
were
contaminated
¤ In
none
of
the
hospitals
dispenser
processing
had
been
adequately
performed
Kampf
et
al.
BMC
Infect
Dis
2014;14:37
Kampf
et
al.
BMC
Infect
Dis
2014;14:37
¤
Roomservice
¤
Roomservice-­‐plus
¤
Registered
nurse
¤
Nurse
asistant
¤
Cleaning
Even
if
you
think
you
know
it,
are
they
actually
doing
it?
ICAN
2014
11

12. Environment
and
HAI
04-­‐11-­‐14
Weber
et
al.
J
Hosp
Infect
2012;80:252-­‐4
¤ Highest
rate
of
mannequin
contamina?on
was
long
sleeves
+
?e
(transmission
occurred
in
4/5
experiments)
and
lowest
with
short
sleeves
no
?e
(0/5).
>
>
Eli:
“flaw
in
this
study
was
that
Fes
were
narrowly
defined
as
neckFes
and
excluded
bow
Fes”
Weber
et
al.
J
Hosp
Infect
2012;80:252-­‐4
h^p://haicontroversies.blogspot.nl
¤ Enter
a
soluFon
to
all
of
our
infecFon
control
problems:
the
Jumbo
Squir?ng
Bow
Tie!
¤ This
oven
overlooked
clothing
accessory
is
a
veritable
infecFon
prevenFon
dream.
² A
bow
Fe
can
increase
our
professionalism
and
limit
pathogen
transmission.
² Add
in
the
"Jumbo
SquirFng"
acFon
and
you
can
squirt
alcohol
hand
rub
into
the
eyes
of
non-­‐compliant
clinicians
(operant
condiFoning)
and
also
into
your
own
hands
to
improve
compliance
with
the
WHO
5
Moments.
h^p://haicontroversies.blogspot.nl
ICAN
2014
12

13. Environment
and
HAI
04-­‐11-­‐14
hZps://www.surveymonkey.com/r/2XG8LV6
ICAN
2014
13