Environmental

SurveillanceFIDSSA 2015

Dr Ben Prinsloo

Medical Microbiologist

The Scientist

• A scientist, in a broad sense, is a person engaging in a systematic activity to acquire knowledge

• We require evidence

• WE NEED AN ANSWER

YES / NO

Lunar Distance

Laser ranging retro reflector

Lunar Distance

HCAI

Hand HygieneActions

Bacterial&FungalPersistence

BMC Infectious Diseases 2006, 6:130

Viral Persistence

Age of Resistance

VRE, MRSA, CRE, ESBL, C difficile, C parapsilosis

• Antibiotic resistant pathogens continues to escalate

Hayden MK. Clin Infect Dis 2006;42:1552-60

HCAI

• HCAI is a major problem for patient safety and its surveillance and prevention must be a first priority

– prolonged hospital stay

– long-term disability

– increased resistance of microorganisms to antimicrobials

– massive additional financial burden

HCAI

• HCAI concerns

– 5–15% of hospitalized patients

– 9–37% of those admitted to intensive care units (ICUs)

– 25 million extra days of hospital stay

– Economic burden of €13–24 billion

Housing Challenge

20x15

R300 billion x1000

R300 000 million/150 000

2 000 000

2.68 million houses built by the state since 1994 according to the 20 Year Review. (134 000/year)

EUR Euro 15.1651409921 0.0659406992

http://www.sanews.gov.za/south-

africa/housing-delivery

The Patient zone

• The patient zone is defined as the patient’s intact skin and his/her immediate surroundings colonized by the patient flora and the healthcare area as containing all other surfaces

My Five Moments for Hand Hygiene

HCAI

Environmental contamination

• Multidrug-resistant (MDR) Acinetobacter baumannii (MDR-AB) is an important nosocomial pathogen

– Prospective cohort study of ICU patients colonized or infected with MDR-AB

– For each patient, 10 surfaces in the patient room were sampled

AJIC Volume 39, Issue 9, November

2011, Pages 711–715

Environmental contamination

• Fifty rooms were sampled

• 48% (24/50) were positive at 1 or more sites

– Supply carts (10/50, 20%)

– Floors (8/50, 16%)

– Infusion pumps (7/50, 14%)

– Ventilator touch pads (5/44, 11.4%)

• Surrounding environment is frequently contaminated

AJIC Volume 39, Issue 9, November

2011, Pages 711–715

The Patient zone

• Patients occupying rooms previously occupied by patients with VRE MRSA, Clostridium difficile, and Acinetobacter baumannii infection or colonization have on average a 73% increased risk of acquiring the same pathogen

Infect Control Hosp Epidemiol 2006;27:127-32 Epub

February 8, 2006

The Patient zone

• Only 40% of near patient surfaces are being cleaned in accordance with existing hospital policies

• Studies have shown thoroughness of disinfection cleaning can be improved to 82% (on average more than 100% over baseline)

Direct Practice Observation

• Covert monitoring of disinfection cleaning can provide an objective assessment of individual ES staff performance and compliance with cleaning protocols

• Cleaning improved from 48% to 87%

• Maintaining such a program

General Principles: Microbiologic Sampling of the Environment

• Before 1970, US hospitals conducted regularly scheduled culturing of the air and environmental surfaces (e.g., floors, walls, and table tops)

• During 1970–1975, 25% of US hospitals reduced the extent of such routine environmental culturing

High-touch surfaces

• The CDC (2003) recommended that hospitals clean and disinfect ‘‘high-touch surfaces”

• Hospitals ‘‘monitor (ie, supervise and inspect) cleaning performance

• Consistent cleaning and disinfection

• Touched by the patient and health care professionals

Swab Cultures

• Limited feasibility of monitoring multiple surfaces in multiple patient rooms as part of an ongoing monitoring program

Environmental Surface Sampling

Routine environmental-surface sampling (e.g., surveillance cultures) in health-care settings is neither cost-effective nor warranted

Environmental surface surveillance can not directly protect a patient from HCAI

1

Support an investigation of an outbreak of disease or infections when environmental

reservoirs or fomites are implicated epidemiologically in disease transmission

2

Environmental sampling may be warranted in research

3

Monitor a potentially hazardous environmental condition

Presence of a hazardous chemical or biological agent

Validate the successful abatement

of the hazard

4

Quality assurance to evaluate the effects of a change in infection-control practice or to

ensure that equipment or systems perform according to specifications and expected

outcomes

Agar Slide Cultures

• Agar coated glass slides with finger holds were developed to simplify quantitative cultures of liquids

• Determine pre-cleaning levels of contamination for each object evaluated in order to accurately assess cleaning practice

Fluorescent Markers

• Surfaces that are effectively disinfected but less effectively cleaned may be more likely flagged as failing to meet a quality standard using one of these markers than one of the culture techniques

• Disinfection cleaning improving from 48% to 77%

ATP Bioluminescence

• A specialized swab is used to sample a standardized surface area

• Total amount of ATP, both microbial and non-microbial, is quantified and expressed as relative light units

Evaluating the Pt Zone

Cleanliness versus cleaning practice

• Observation and fluorescent gel systems directly evaluate the cleaning process

• The swab or slide culture as well as ATP bioluminescence systems measure cleanliness

• Intrinsically low concentration of most major HAPs on surfaces limits the use of pathogen-specific monitoring

ICE

Creepy Crawlies

• Cockroaches

– Gram-negative bacteria • Acinetobacter spp.; Citrobacter freundii; Enterobacter spp., E. cloacae;

Escherichia coli; Flavobacterium spp.; Klebsiella spp.; Proteus spp.; Pseudomonas spp., P. aeruginosa, P. fluorescens, P. putida; Salmonella spp.; Serratia spp., S. marcescens; Shigella boydii

– Gram-positive bacteria • Bacillus spp.; Enterococcus faecalis; Micrococcus spp.; Staphylococcus

aureus, S. epidermidis; Streptococcus spp., S. viridans

– Fungi• Aspergillus niger; Mucor spp.; Rhizopus spp. Candida spp. (houseflies)

Conclusions

• Hand Hygiene

• Bacterial Persistence of MDR organisms

• Patient zone

• Monitoring / Evaluation

“Clutter and confusion are failures of design, not attributes of information.” — Edward Tuft

“Don’t make the process harder than it is.“ — Jack Welch