The document discusses various studies related to hand hygiene, environmental contamination, and infection control in healthcare settings. It highlights the effectiveness of different cleaning methods and PPE compliance, noting no significant difference in MRSA and VRE acquisition between intervention and control groups. Additionally, it addresses challenges related to microbial resistance and the potential role of toys in promoting hygiene, along with the importance of monitoring and improving compliance in infection prevention strategies.

1. 05-­‐10-­‐15
1
Prof.
Dr.
Andreas
Voss
Radboud
umc
Canisisus-­‐Wilhelmina
Hospital
Nijmegen,
The
Netherlands
¤
Hand
hygiene
¤
Environment
&
machines/scopes
¤
FighKng
MDROs
¤
Skin
disinfecKon/decolonizaKon
¤
SSI
&
OperaKng
Room
…
oder
besser
!
JAMA
Intern
Med.
doi:10.1001/jamainternmed.2014.6781
Published
online
December
22,
2014
InfecKon
control
talks
are
generally
rated
as
“therapeuKc”
for
HCWs
with
sleeping
disorders.

2. 05-­‐10-­‐15
2
¤
35
hospitals,
56
nursing
homes
¤
>4000
HCWs
from
56
nursing
units
¤
13.8
million
HH
opportuniKes
captured
via
RFRD
¤
HH
compliance
²
Start
of
shi_:
42.6%
²
End
of
shi_:
34.8%
Dia
et
al.
J
Appl
Psychol
2014
Isaacson
et
al.
AJIC
2015:43;530
¤
14
HCWs
¤
Nontoxogenic
spores
of
C.
difficile
pipebed
onto
hands
¤
6-­‐study
arms
in
random
order
Isaacson
et
al.
AJIC
2015:43;530
No
hand
washing
Medicated
soap
Isaacson
et
al.
AJIC
2015:43;530
Water
alone
rubbing
&
rising
Water
alone
rising
only
Rubing
with
sand
than
rising
Rubing
with
baking
soda
and
oil,
than
dish-­‐detergent,
than
rising
1.98
2.34
1.90
1.84
2.21
Isaacson
et
al.
AJIC
2015:43;530

3. 05-­‐10-­‐15
3
Harris
et
al.
JAMA
2013;310:1571
¤
Cluster-­‐randomized
trial
in
20
medical
and
surgical
ICUs
in
20
US
hospitals.
¤
IntervenKon
=
Universal
gloves
&
gown
use
versus
gloves
&
gown
for
known
MRSA
and
VRE
paKents
¤
Primary
outcome
was
acquisiKon
of
MRSA
or
VRE
based
on
surveillance
cultures
collected
on
admission
and
discharge
from
the
ICU.
Harris
et
al.
JAMA
2013;310:1571
¤
The
use
of
gloves
and
gowns
for
all
paKent
contact
compared
with
usual
care
among
paKents
in
medical
and
surgical
ICUs
did
not
result
in
a
difference
in
the
primary
outcome
of
acquisiKon
of
MRSA
or
VRE
¤
No
difference
in
individual
VRE-­‐acquisiKon
¤
Less
individual
MRSA-­‐acquisiKon
Harris
et
al.
JAMA
2013;310:1571
environm
ent
hands
¤
Compliance
with
gloves
&
gowns
was
about
85%
in
intervenKon
group,
80%
in
control
¤
HH
compliance
56%
vs
51%
(intervenKon
versus
control
group)
¤
Is
it
even
possible
to
show
a
difference
with
regard
to
one
IC
measure
in
a
high
prevalence
semng?
Harris
et
al.
JAMA
2013;310:1571

4. 05-­‐10-­‐15
4
¤
Highest
transfer
of
bacteria:
handshake
¤
Lowest
transfer
of
bacteria:
fist
bump
(high
five
was
in
the
middle)
¤
ExplanaKon:
handshakes
have
the
greatest
surface
area
in
contact,
for
a
longer
Kme
Mela
et
al.
Am
J
Infect
Control
2014;42:916-­‐7
Yoh
doc
¤
Hand
hygiene
¤
Environment
&
machines/scopes
¤
FighKng
MDROs
¤
Skin
disinfecKon/decolonizaKon
¤
SSI
Vandini
et
al
PLoS
ONE
2014;
9:
e108598.
doi:10.1371/journal.pone.0108598
Bacillus
subDlis,
Bacillus
pumilus
and
Bacillus
megaterium

5. 05-­‐10-­‐15
5
Vandini
et
al
PLoS
ONE
2014;
9:
e108598.
doi:10.1371/journal.pone.0108598
Microbial-­‐based
cleaning
started
ConvenKonal
cleaning
started
E.coli
S.
aureus
…
but
(methods)
Thom
et
al.
Infect
Control
Hosp
Epidemiol
2014;35:1060-­‐62
Thom
et
al.
Infect
Control
Hosp
Epidemiol
2014;35:1060-­‐62
¤
MSDS
Poly
spray
(silicone
quaternary
amine)
¤
8
surfaces
²
sink,
call
bubon,
bedside
table,
monitor,
telephone,
supply
cart,
door
handle,
floor
¤
Results:
² No
significant
effect
on
environmental
contaminaKon
Thom
et
al.
Infect
Control
Hosp
Epidemiol
2014;35:1060-­‐62
¤
Problem
adherence?
¤
Love
the
concept
of
changing
the
surface
¤
Studies
with
copper,
silver
silica,
Biosafe
HM
4100
(polymer)
embedded
in
polyurethane,
light-­‐acKvated
anKmicrobials,
…
have
worked
before
Freeman
et
al.
AnKmicrob
Resistance
Infect
Control
2014;3:5

6. 05-­‐10-­‐15
6
¤
We
systemaKcally
sampled
8
surfaces
in
the
rooms
and
bathrooms
of
adult
paKents
colonized
or
infected
with
ESBL-­‐EC
or
ESBL-­‐KP
throughout
their
hospital
stay.
¤
Environmental
contaminaKon
was
defined
as
recovery
of
an
ESBL-­‐producing
organism
matching
the
source
paKent’s
isolate
Freeman
et
al.
AnKmicrobial
Resistance
and
InfecKon
Control
2014,
3:5
¤
Freeman
et
al.
AnKmicrobial
Resistance
and
InfecKon
Control
2014,
3:5
Freeman
et
al.
AnKmicrobial
Resistance
and
InfecKon
Control
2014,
3:5
Rooms
of
paKents
with
ESBL-­‐KP
have
substanKally
higher
contaminaKon
rates
than
those
with
ESBL-­‐EC.
This
finding
may
help
explain
the
apparently
higher
transmissibility
of
ESBL-­‐KP
in
the
hospital
semng
Kampf
et
al.
BMC
Infect
Dis
2014;14:37
Kampf
et
al.
BMC
Infect
Dis
2014;14:37
¤ Reusable
Kssue
dispensers
with
different
surface
disinfectants
were
randomly
collected
from
healthcare
faciliKes.
¤ 66
dispensers
containing
disinfectant
soluKons
with
surface-­‐acKve
ingredients
were
collected
in
15
healthcare
faciliKes.
28
dispensers
from
nine
healthcare
faciliKes
were
contaminated
¤ In
none
of
the
hospitals
dispenser
processing
had
been
adequately
performed
…
it
is
not
about
the
details
of
this
paper,
but
the
point
that
even
“helpful
parts
of
the
environment”
may
be
a
source
for
infecKons
¤
NIH
program
to
encourage
handwashing
in
hospitals
and
day
care
centers
¤
Program
promotes
a
symbolic
teddy
bear
(T.
Bear)
with
slogans/reminders
to
pracKce
HH.
¤
Stuffed
T.
Bear
was
dispensed
to
the
hospitalized
child.
¤
Could
T.
Bear
serve
as
a
"fomite”?
Hughes
et
al.
Infect
Control.
1986
Oct;7(10):495-­‐500

7. 05-­‐10-­‐15
7
¤ ProspecKve
study
of
39
sterilized
T.
Bears,
one
week
a_er
use:
² S.aureus,
K.pneumoniae,
P.aeruginosa,
E.coli,
Candida
spp,
Cryptococcus,
Aspergillus
and
others.
² Although
the
T.
Bear
handwashing
campaign
should
not
be
discredited,
the
promoKonal
toy
may
pose
an
unnecessary
expense
and
hazard
and
should
not
be
used
in
hospitals.
Hughes
et
al.
Infect
Control.
1986
Oct;7(10):495-­‐500
110
paKent
encounters
Ama
et
al.
Infect
Control
Hosp
Epidemiol
2013;34:1331
18
40
28
23
Ama
et
al.
Infect
Control
Hosp
Epidemiol
2013;34:1331
Cleaning
of
equipement
14%
before
and
a_er
use
PaKent
in
contact
isolaKon
24%
PaKent
not
in
contact
isol.
7%
LongKn
et
al.
Mayo
Clin
Proc
2014;89:291-­‐299

8. 05-­‐10-­‐15
8
Sax
et
al.
Clin
Infect
Dis
April
15,
2015
Sax
et
al.
Clin
Infect
Dis
April
15,
2015
Sax
et
al.
Clin
Infect
Dis
April
15,
2015
First
6
cases
Sax
et
al.
Clin
Infect
Dis
April
15,
2015
Takes
years
to
develop
Aerogenic
spread

9. 05-­‐10-­‐15
9
¤
NDM1-­‐producing
E.
coli
in
2013
¤
Case-­‐Control
Study
²
ERCP
procedure:
OR
78
²
AnKbioKcs:
OR
9
¤
Cohort
Study
²
mulKple
endoscope
exposures
(71%)
more
likely
to
have
NDM1-­‐producing
E.
coli.
Single
exposure
–
41%.
Eppstein
et
al.
JAMA
2014;312
¤
Clonal
outbreak
of
22
paKents
with
VIM-­‐
posiKeve
P.
aeruginosas
¤
Common
denomintor:
ERCP
(Olympus
Q180)
¤
DestrucKve
cultures
of
scope
–
idenKcal
micro-­‐
organism
under
“elevator”
¤
A_er
excluding
scope
from
use
–
no
further
cases
Verfaille
et
al.
Endoscopy
2015;47:493
¤ A.
fumigatus
in
reverse
osmosis
unit
supplying
10
endoscope
re-­‐processors
with
water
for
final
rinse
¤ MulKple
abempts
to
disinfect
machines,
basins
and
water
purificaKon
system
failed
Khalsa
et
al.
Am
J
Infect
Control
2014;1-­‐3
Only
replacement
of
all
filters
and
RO
membrane
solved
the
problem:
“breakthrough
growth”
¤
Hand
hygiene
¤
Environment
&
machines/scopes
¤
FighKng
MDROs
¤
Skin
disinfecKon/decolonizaKon
¤
SSI

10. 05-­‐10-­‐15
10
hbp://www.cddep.org
hbp://www.cddep.org
Bibe
selber
lesen
–
jetzt
keine
Zeit
PLOS
ONE
|
DOI:10.1371/journal.pone.0116746
March
18,
2015
PLOS
ONE
|
DOI:10.1371/journal.pone.0116746
March
18,
2015
PLOS
ONE
|
DOI:10.1371/journal.pone.0116746
March
18,
2015
…
poor
governance
and
corrupKon
contributes
to
levels
of
anKbioKc
resistance
and
correlate
beber
than
anKbioKc
usage
volumes
with
resistance
rates

11. 05-­‐10-­‐15
11
Gastmeier
et
al.
JAC
2014;6:1660
Gastmeier
et
al.
JAC
2014;6:1660
Data
from
German
naKonal
nosocomial
surveillance
system
(KISS)
Gastmeier
et
al.
JAC
2014;6:1660
SSI
UTI
BSI
Gastmeier
et
al.
JAC
2014;6:1660
The
high
overall
VRE
proporKon
in
Germany
is
mainly
due
to
the
situaKon
in
four
states
(Rhine-­‐Westphalia,
Hesse,
Thuringia
and
Saxony
).
There
is
an
urgent
need
to
analyse
the
epidemiology
of
VRE
in
detail
to
develop
appropriate
infecKon
control
strategies
Jurke
et
al.
Euro
Surveill.
2013;18(36):pii=20579
¤ In
2007,
all
hospitals
started
to
systemaKcally
screen
defined
paKents
associated
with
any
one
of
the
known
risk
factors,
prior
to
or
upon
admission
to
a
hospital.
¤ From
2007
to
2011,
the
MRSA
admission
incidence
(0.51
vs
1.09
MRSA
cases/100
paKents
admibed),
the
MRSA
incidence
density
(0.87
vs
1.54
MRSA
cases/
1,000
paKent
days)
as
well
as
the
mean
daily
MRSA-­‐
burden
(1.30
vs
1.82
MRSA-­‐in-­‐hospital
days/100
paKent
days)
increased
significantly
(p<0.0001)
Jurke
et
al.
Euro
Surveill.
2013;18(36):pii=20579

12. 05-­‐10-­‐15
12
Jurke
et
al.
Euro
Surveill.
2013;18(36):pii=20579
MRSA
Screenings
Paradox
=
Wer
sucht
–
der
findet
!
Fätkenheuer
et
al
Lancet
2014,
published
online
Aug
21st
Fätkenheuer
et
al
Lancet
2014,
published
online
Aug
21st
Fätkenheuer
et
al
Lancet
2014,
published
online
Aug
21st
Hand hygiene +++Screening
?Isolation
Decolonization +
“the
strategy
of
screening
and
isolaFon
cannot
be
regarded
as
a
gold
standard
to
prevent
the
spread
of
MRSA”
…
okay,
but
what
did
we
do
in
the
NL
–
screen
&
isolate
and
20%
HH
compliance
Hetem
et
al.
Emerging
Infect
Dis
2013;19:1797

13. 05-­‐10-­‐15
13
Hetem
et
al.
Emerging
Infect
Dis
2013;19:1797
Transmissibility
of
LA-­‐MRSA
is
(sKll)
4.4
Kmes
lower
than
that
of
other
MRSA
(not
associated
with
livestock)
IN THE MRSA EPIDEMIOLOGY
¤
sequence
type
(ST)
8
community-­‐associated
geneKc
lineage,
SCCmec
type
IVa,
spa
type
t292
related
to
MRSA
lineage
USA300
Rossi
et
al.
NEJM
2014,370:1524
Rossi
et
al.
NEJM
2014,370:1524
IN THE MRSA EPIDEMIOLOGY
Hearing CA-MRSA
USA300 & vanco-
resistance in one
strain gives me the
creeps …
¤
Hand
hygiene
¤
Environment
&
machines/scopes
¤
FighKng
MDROs
¤
Skin
disinfecKon/decolonizaKon
¤
SSI
Maiwald
&
Chan
J
AnKmicrob
Chemother
2014;69:2017

14. 05-­‐10-­‐15
14
Maiwald
&
Chan
J
AnKmicrob
Chemother
2014;69:2017
chlorhexidine
alcohol
Povidone-­‐iodine
Charehbili
Surg
Infect
2014;15:DOI:
10.1089/sur.2012.185
¤
Single
center,
non-­‐randomized,
non-­‐blinded,
retrospecKve
study
¤
2010
and
prior:
1%
iodine
in
70%
alcohol
¤
2011
and
a_er
a
preparaKon
of
0.5%
chlorhexidine
in
70%
alcohol
¤
SSI
according
to
naKonal
surveillance
definiKon
¤
Protocol
for
prevenKng
SSI
did
not
differ
during
the
two
years
in
which
the
study
was
conducted
(?)
Charehbili
Surg
Infect
2014;15:DOI:
10.1089/sur.2012.185
Charehbili
et
al.
Surg
Infect
2014;15:DOI:
10.1089/sur.2012.185
Mimoz
et
al.
Lancet
published
on-­‐line
Sept
18th,
2015
¤
11
French
intensive-­‐care
units
¤
PaKents
requiring
at
least
one
of
central-­‐venous,
haemodialysis,
or
arterial
catheters.
¤
Before
catheter
inserKon,
we
randomly
assigned
paKents
to
have
all
intravascular
catheters
prepared
with
2%
chlorhexidine–70%
isopropyl
alcohol
or
5%
povidone
iodine–69%
ethanol,
with
or
without
scrubbing
of
the
skin
with
detergent
before
anKsepKc
applicaKon.
¤
Primary
outcome
was
the
incidence
of
catheter-­‐related
infecKons
in
the
intenKon-­‐to-­‐treat
populaKon.
Mimoz
et
al.
Lancet
published
on-­‐line
Sept
18th,
2015

15. 05-­‐10-­‐15
15
Mimoz
et
al.
Lancet
published
on-­‐line
Sept
18th,
2015
Mimoz
et
al.
Lancet
published
on-­‐line
Sept
18th,
2015
¤
Use
of
2%
CHX–alcohol
for
skin
anKsepsis
was
associated
with
6-­‐fold
decreases
in
the
incidences
CR-­‐infecKon
and
catheter
colonisaKon
and
a
5-­‐fold
decrease
in
the
incidence
of
CR-­‐BSI.
¤
Skin
scrubbing
before
anKsepKc
applicaKon
had
no
further
effect
¤
Adverse
skin
reacKons
were
rare
but
more
common
with
CHX–alcohol
than
with
povidone
iodine–alcohol.
Mimoz
et
al.
Lancet
published
on-­‐line
Sept
18th,
2015
Prag
et
al.
APMIS
2014;122:961-­‐7
¤ Decreased
suscepKbility
to
chlorhexidine
was
found
in
54%
of
PJI
isolates,
68%
of
cardiac
isolates,
21%
of
commensal
isolates,
and
7%
of
skin
isolates
from
cardiac
paKents,
respecKvely.
¤ The
qacA/B
gene
was
found
in
52%
of
PJI
isolates,
61%
of
cardiac
isolates,
25%
of
commensal
isolates,
and
19%
of
the
skin
isolates.
Prag
et
al.
APMIS
2014;122:961-­‐7
Steed
et
al.
Am
J
Infect
Control
2014

16. 05-­‐10-­‐15
16
Steed
et
al.
Am
J
Infect
Control
2014
Steed
et
al.
Am
J
Infect
Control
2014
¤
Very
effecKve
in
reducing
the
bacterial
load,
but
…
¤
…
2
hours
a_er
last
applicaKon:
what
is
the
bacterial
load
in
the
next
morning?
¤
…
no
informaKon
about
effect
a_er
mulKple
day
use
(load
reducKon?,
side
effects?)
¤
…
no
informaKon
on
the
percentage
of
HCWs
that
became
MRSA-­‐free
Bryce
et
al.
J
Hosp
Infect
2014;
doi:
10.1016/j.jhin.2014.06.017.
[Epub
ahead
of
print]
¤
Hand
hygiene
¤
Environment
&
maschines/scopes
¤
FighKng
MDROs
¤
Skin
disinfecKon/decolonizaKon
¤
SSI
&
OperaKng
Room
Merollini
et
al.
AJIC
2013
in
press

17. 05-­‐10-­‐15
17
Conclusion
¤ PrevenKng
deep
SSI
with
anKbioKc
prophylaxis
and
anKbioKc-­‐impregnated
cement
has
shown
to
improve
health
outcomes
among
hospitalized
paKents,
save
lives,
and
enhance
resource
allocaKon.
¤ Based
on
this
evidence,
the
use
of
laminar
air
operaFng
rooms
is
not
recommended.
Merollini
et
al.
AJIC
2013
in
press
Gastmeier
et
al.
JHI
2012;81:73-­‐78
Leape
NEJM
2014;
370:1063-­‐64
Urbach
et
al.
NEJM
2014;
370:1029-­‐38
¤
InformaKon
on
the
use
of
surgical
safety
checklists
from
130
of
133
hospitals
¤
200,000
surgical
procedures
¤
Inclusion
of
3
months
before
the
introducKon
of
a
surgical
checklist,
and
one
starKng
3
months
a_er
the
introducKon
of
the
checklist
Urbach
et
al.
NEJM
2014;
370:1029-­‐38
Urbach
et
al.
NEJM
2014;
370:1029-­‐38
¤ It
is
not
the
act
of
Kcking
off
a
checklist
that
reduces
complicaKons,
but
performance
of
the
acKons
it
calls
for
¤ Implement
the
behavioral
change
² demonstrate
the
need
for
change,
engage
leadership,
provide
training
in
teamwork,
make
HCW
accountable
¤ Provide
local
teams
with
direcKon,
coaching,
training,
data
management,
opportunity
to
learn
from
others
¤ “Gaming”
¤
Full
implementaKon
needs
Kme
Leape
NEJM
2014;
370:1063-­‐64
“The
likely
reason
for
the
failure
of
the
surgical
checklist
in
Ontario
is
that
it
was
not
actually
used”

18. 05-­‐10-­‐15
18
¤ RCT
of
non-­‐emergency
cardic
surgery
in
17
UK
centers
¤ If
hemoglobin
level
<9g/dl
randomly
assigned
to
one
of
the
study
groups:
² Liberal
transfusion
threshold:
Hb
<
9
g/dl
²
ResitricKve
transfuion
threshold:
Hb
<
7.5
g/dl
Murphey
et
al.
NEJM
March
2015;372
¤ Serious
infecKon
(sepsis
or
wound
infecKon)
or
an
ischemic
event
occurred
in
35.1%
of
the
paKents
in
the
restricKve-­‐threshold
group
and
33.0%
of
the
paKents
in
the
liberal-­‐threshold
group
(odds
raKo,
1.11;
95%
confidence
interval
[CI],
0.91
to
1.34;
P=0.30).
¤ There
were
more
deaths
in
the
restricKve-­‐
threshold
group
than
in
the
liberal-­‐threshold
group
(4.2%
vs.
2.6%;
hazard
raKo,
1.64;
95%
CI,
1.00
to
2.67;
P=0.045).
Murphey
et
al.
NEJM
March
2015;372
Schweizer
et
al.
JAMA
2015;313:2162
¤ Evaluate
implementaKon
of
SSI
bundle
in
20
hospitals
in
9
US
states
¤ Primary
outcome
deep
and
organ
space
infecKons
¤
Bundle
(screening,
decolonizaKon
and
profylaxis)
achieved
a
moderst,
staKsKcally
significant
effect
Schweizer
et
al.
JAMA
2015;313:2162
Schweizer
et
al.
JAMA
2015;313:2162
Bebko
et
al.
JAMA
Surgery
2015;150:390

19. 05-­‐10-­‐15
19
EducaKonal
video
CHX
washcloths
CHX
oral
rinse
Nasal
povidone-­‐iodine
Bebko
et
al.
JAMA
Surgery
2015;150:390
Bebko
et
al.
JAMA
Surgery
2015;150:390
Bebko
et
al.
JAMA
Surgery
2015;150:390