using a sporicidal disinfectant …using a sporicidal disinfectant everywhere is not the solution to...
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USING A SPORICIDAL DISINFECTANT EVERYWHERE
IS NOT THE SOLUTION TO ONGOING CLOSTRIDIUM
DIFFICILE TRANSMISSION
Jim Gauthier, MLT, CIC
Senior Clinical Advisor, Infection Prevention
Objectives
• Review impact of Clostridium difficile Infection (CDI)
• Understand literature and recommendations to
prevent the risk of CDI in the healthcare
environment
• Understand when moving to special practices may
make sense
• Explore bundled approaches and evidence-based
options to reduce CDI risk
• Spore-forming, Gram-positive
anaerobic bacillus
• Most common cause of healthcare-
associated diarrhea
• Opportunistic bacteria – usually needs
a change in gut flora to grow and
produce toxins (antibiotics,
chemotherapy)
3
Clostridium difficile
Clostridium difficile
• C. difficile spores pose unique challenges for hand
hygiene and disinfection practices since they are
resistant to the bactericidal effects of alcohol hand rubs
and many common disinfectants
• Some studies have shown spores are also difficult to
wash off of hands
Clostridium difficile
• CDI rates are increasing - C. difficile now rivals
MRSA as the most common cause of HAIs in the
United States
• CDI has moved outside of the hospital walls, with
more than 50% of CDIs having onset in the
community and more than 75% of CDI cases having
onset outside the acute care hospital
Strategies to Prevent Clostridium difficile Infections in Acute Care Hospitals: 2014 Update Author(s): Erik R. Dubberke, MD, MSPH; Philip Carling, MD; Ruth Carrico, PhD, RN; Curtis J. Donskey, MD; Vivian G. Loo, MD, MSc; L. Clifford McDonald, MD; Lisa L. Maragakis, MD, MPH; Thomas J. Sandora, MD, MPH; David J. Weber, MD, MPH; Deborah S. Yokoe, MD, MPH; Dale N.Gerding, MD Source: Infection Control and Hospital Epidemiology, Vol. 35, No. 6 (June 2014), pp. 628-645
Clostridium difficile
• CDI present on admission to the hospital may increase
the risk of CDI for other patients
• CDI is associated with increased length of stay (2.8 – 5.5
days), morbidity and death and is estimated to add up to
$4.9 billion in excess cost
Strategies to Prevent Clostridium difficile Infections in Acute Care Hospitals: 2014 Update
• A collaboration of key industry experts highlighting
practical recommendations to assist acute care hospitals
with Clostridium difficile infection (CDI) prevention efforts
• Updates the 2008 “Strategies to Prevent Clostridium
difficile infections in Acute Care Hospitals”
• This guidance document is collaborative effort led by
SHEA, IDSA, AHA, APIC and the Joint Commission
SHEA/IDSA Practice Recommendation
Strategies to Prevent Clostridium difficile
Infections in Acute Care Hospitals
General Strategies to Prevent CDI
• Antimicrobial usage restriction and stewardship
• Restriction of specific high-risk antimicrobials has been
effective in outbreak settings
• Improving antimicrobial prescribing practices has been
effective in outbreak and non-outbreak settings
General Strategies to Prevent CDI
• Prevent patient exposure to C. difficile (disinfection and
barrier methods) • Avoid use of electronic thermometers
• Use of dedicated patient care items and equipment
• Use of contact precautions (gowns/gloves)
• Private rooms/isolation; preference to those with fecal incontinence
• Hand hygiene
• Environmental cleaning and disinfection; sporicidal for outbreak or
hyperendemic situations
• Staff, Patient and Visitor Education
Transmission of C. difficile
• Patient-to-patient transmission of C. difficile is thought to
occur primarily through transient contamination of the
hands of healthcare personnel (HCP)
• Glove use when caring for patients with CDI or touching
surfaces in their rooms has been shown to be effective
in preventing transmission
Transmission of C. difficile
• Daily disinfection of high touch surfaces in CDI rooms
has been shown to reduce acquisition of pathogens on
hands after contact with surfaces and to decrease
contamination of the hands of the providers caring for
patients
Transmission of C. difficile • Sharing a room with a patient diagnosed with CDI or being
admitted to a room after a patient with CDI was
discharged from that room, have not been found to
increase the risk factor for CDI in several studies
• Several studies have found that the use of sporicidal
methods to clean the environment, outside of outbreak
settings, has not consistently demonstrated a reduction of
CDI, which indicates that although the environment can be
an important source for C. difficile, indirect transmission by
healthcare professionals may be the major route by which
patients acquire C. difficile
Ensure Cleaning and Disinfection of
Equipment and the Environment
• C. difficile spores contaminate the environment in which
patients are housed and the equipment used to care for
them. This includes the following:
• Furnishings in the room, such as overbed tables, bedrails,
furniture, sinks, floors, commodes, and toilets
• Patient care equipment that directly touches patients, such as
thermometers, stethoscopes, and blood pressure cuffs
Basic Practices vs. Special Approaches Basic practices – should be adopted by all acute care hospitals –
includes recommendations where the potential to impact HAI risk
clearly outweighs the potential for undesirable effects
Special approaches – can be considered for use in locations and/or
populations within hospitals when HAIs are not controlled by use of
basic practices – these can include recommendations where the
intervention is likely to reduce HAI risk, but where there is concerns
about the risk of undesirable outcomes; where the quality of evidence is
low; or when evidence supports the intervention in select settings or for
select patient populations
C. Diff isolation
Task Oriented vs.
Daily Use
Before Moving to Special Practices
• Develop and implement protocols for disinfection of equipment and
the environment • On a routine basis, assess adherence to protocols and the adequacy of
cleaning and disinfection
• Assess the adequacy of cleaning and disinfection practices before
changing to a new cleaning product (e.g., bleach). If cleaning and
disinfection practices are not adequate, address this before changing
product
• Ensure patient care equipment and electronic equipment that remain in
the patient room are cleaned and disinfected
• Educate environmental service personnel on proper cleaning and
disinfection technique and ensure competency
Are Your HAI rates still high?
Review basic practices
+
Rutala 2014
~27%
+
Rutala 2014
~53%
+
Rutala 2014
79%
(without
Yeasts)
Effect of Disinfectants on Microorganisms Organism Type Examples
Bacterial Spores Spore Bacillus anthracis, Clostridium difficile
Mycobacteria Bacteria M. tuberculosis
Small non-enveloped virus Virus Poliovirus, Norovirus
Fungal spores Fungus Aspergillus, Penicillium, Trichophyton
Gram negative bacteria Bacteria E. coli, Klebsiella including CRE,
Pseudomonas, Acinetobacter
Fungi (Vegetative) Fungus Candida
Large Virus (non-enveloped) Virus Adenovirus, Rotavirus
Gram positive bacteria Bacteria Staphylococcus including MRSA
Enterococcus including VRE
Virus (enveloped) Virus HIV, HBV, HCV, Influenza
^Resistant * Sensitive
R^
S*
Adapted from Rutala et al. ICHE 2014;35(7):862
Evaluate the Risk of Soiling
Procedure
Incontinent product change (feces)
Assisting a vomiting patient
Performing a bed bath
Open Suctioning
Wound dressing change
Removing Central Line
Removing urinary or peripheral catheter
Phlebotomy
Dressing patient
Placing or removing food tray
^Hi Soiling Risk * Low Soiling Risk
HS^
LS*
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Is Hand Hygiene Your Issue?
• Do staff, visitors and patients understand the
importance?
• Do they know when to perform hand hygiene?
• Do they understand what product is to be used?
• Is the product accessible – when and where they need
it?
• Are they using the appropriate technique?
Is Environmental Cleaning and
Disinfection Your Issue?
• Do all staff members understand why cleaning and
disinfection so important?
• Is it clearly defined who is responsible for cleaning what
(EVS, nursing, other)?
Cleaning and Disinfection
• What surfaces/equipment need to be cleaned, how
often, what product should be used, what cleaning tool,
compatibility of cleaning tool to disinfectant, what
dilution, amount needed, contact time?
• Is there product available where/when needed?
• Is the product being used properly, PPE donned
correctly (if needed), right technique used, contact time
achieved, feedback provided?
Cleaning and Disinfection
• Assess the adequacy of room cleaning • If room cleaning and disinfection practices are deemed to be
inadequate, focus on reviewing and improving cleaning and
disinfection techniques
• Create a unit-specific checklist based on cleaning protocols and
perform observations to monitor cleaning practice
• Consider environmental decontamination with sodium hypochlorite
or EPA-approved sporicidal agent if room cleaning and disinfection
is deemed to be adequate but there is ongoing CDI transmission
Strategies to Prevent Clostridium difficile Infections in Acute Care Hospitals: 2014 Update
Numerous studies indicate that environmental
cleaning in patient rooms is suboptimal • Carling conducted two multi-facilities studies that demonstrated that on
average less than 50% of high touch surfaces were cleaned thoroughly
• Significant variation existed within object categories – with ranges
between 0-90%
Carling 2008
Sporicidal Concerns
• Data are conflicting as to whether inactivation of spores is necessary
to prevent C. difficile transmission, especially in an endemic setting
• Sporicidal agents can be harsh on surfaces • Discoloration
• Shorter Asset Life Cycle
• Oxidation and wear
• Sporicidal agents can be harsh on people • Asthmagen
• Foul odor
• Irritating to lungs, skin, eyes
SHEA Poster Presentation
Change Management Plan – Interventions • Stakeholder meetings
• Education
• Cleaning carts and checklists
• Daily duties distributed to staff
• Switched to sporicidal for daily cleaning
Study results raised
the question:
Are people not using
disinfectant because
they are concerned? Derya Mahmutoglu, MD, Javeria Haque, MD, Mary Beth Graham, MD and L. Silvia Munoz-Price, MD PhD, Division of Infectious Diseases, Medical College of WI
Use of Sporicidal Agents
• Data on the ability of sporicidal agents used to control CDI in the
environment have not been consistent; however a beneficial effect has
been reported when used in outbreak or hyperendemic settings when used
with other enhanced CDI control measures
• When in use:
• Avoid toxicity to patients and staff and damage to the equipment and the
environment from use.
• Sodium hypochlorite can be corrosive and irritating to patients and
healthcare workers
• Coordinate activities with EVS, IP to determine when/how it will be used
Strategies to Prevent Clostridium difficile Infections in Acute Care Hospitals: 2014 Update
Are There Alternative Options?
Elbow grease does the job
Efficacy of Different Cleaning and Disinfection Methods
against Clostridium difficile Spores: Importance of
Physical Removal versus Sporicidal Inactivation • Tested the removal of C. difficile spores from environmental surfaces using
various cleaners, disinfectants and wipes. Wipes with a non-sporicidal
agent showed 2.9 log10 reductions of C. difficile spores. Wiping with a
sporicidal agent increased the removal efficacy by 1 log10 (3.9 log10)
• Results: Any method that included wiping the surface (physical removal)
resulted in a 3 log10 reduction in C. difficile spores, even if the cleaner or
disinfectant was not a sporicidal agent
Rutala 2012 ICHE
C. difficile Eradication from Toilets
Few alternatives to bleach for non-outbreak conditions
have been evaluated in controlled healthcare studies
METHODS
• This study was a prospective clinical comparison during non-outbreak
conditions of the efficacy of a disinfectant cleaner (0.5% IHP) with respect to
spore removal from toilets in a tertiary care facility
CONCLUSION
• 0.5% IHP formulation evaluated has shown some sporicidal activity (2-3
log10 kill after 1 minute) and provides a one-step process that significantly
lowers the C. difficile spore level in toilets during non-outbreak conditions
without the workplace safety concerns associated with 5000 ppm bleach Alfa 2010
36
Reducing the risk is more than just using a disinfectant
It takes an integrated approach designed to protect people and assets
with effective products, procedures and a validation program designed
to objectively measure cleaning and disinfection effectiveness.
Key Elements of HAI Reduction
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A clearly defined protocol with education
Compliance monitoring with staff feedback
The use of an effective disinfectant cleaner
First Clinical study to show that improved compliance with environmental surface disinfection using IHP reduced HAI rates for VRE, MRSA and C. difficile
Alfa 2015
Proven Solution to Reduce HAI
First Clinical study to show that improved compliance with environmental surface disinfection using IHP reduced HAI rates for VRE, MRSA and C. difficile
Alfa 2015
Proven Solution to Reduce HAI
All rates reduced by > 20%
First Clinical study to show that improved compliance with environmental surface disinfection using IHP reduced HAI rates for VRE, MRSA and C. difficile
3 key components to ensure reduction of HAI:
Alfa 2015
Cost avoidance of $668,000/year due to HAI rate reduction
Proven Solution to Reduce HAI
All rates reduced by > 20%
A clearly defined protocol with education
Compliance monitoring with staff feedback
The use of an effective disinfectant cleaner
A New Study with Improved Hydrogen
peroxide (IHP) Presented at APIC
John M. Boyce, MD Presented at APIC 2016
AJIC 2016;44(6)Suppl:S16
Study Design
• 12-month prospective trial with cross-over design conducted on two
campuses of a university-affiliated hospital
• On each campus, 2 wards were randomized to have housekeepers perform
routine daily cleaning/disinfection of surfaces
• IHP disinfectant wipes containing 0.5% IHP
• Quat disinfectant currently used in the hospital, applied using a disposable wipe
made of meltblown polypropylene (same material as disposable wipe above)
• The 4 study wards included
• An MICU and its step-down unit on one campus
• Two general medical wards on the other campus
• After the initial 6 months, ward assignments were changed
Results
• Mean Aerobic Colony Count (ACC)/surface after cleaning
• On IHP wards (14.0 CFUs/surface)
• On Quat wards (22.2 CFUs/surface)
(p = 0.003)
• Logistic regression analysis revealed that the proportion of surfaces
yielding no growth after cleaning
• On IHP wards (240/501 [47.9%])
• On Quat wards (182/517 [35.2%])
(p < 0.0001)
Both microbiological outcomes favored IHP over Quat
Results
23% fewer cases/1000 Pt-days on IHP wards
• Hand hygiene compliance rates comparable on study wards • Antibiotic usage: Non-C. difficile agent use was 10.8% higher on IHP wards which would
be expected to lead to more VRE, MRSA and CDI outcomes, not fewer as observed
)
Proven Formula for HAI Reduction
45
A clearly defined protocol with education
Compliance monitoring with staff feedback
The use of an effective disinfectant cleaner
Additional Learnings
• It is critical to ensure there is a proper process, procedure and
training program in place, along with an objective means to
measure compliance
• Also, there is no substitute for good hand hygiene!!
Summary
47
48
C. Diff isolation
Task Oriented vs. Daily Use
Why you don't need to use a C. diff
sporicidal everywhere
1. Guidelines recommend sporicidal
disinfectants during hyperendemic or
outbreak situations; not for daily
cleaning
2. Data on use of sporicidal agents to
control CDI has been inconsistent
3. Potential negative side effects of
sporicidal agents (air quality,
equipment compatibility, worker and
patient safety) may outweigh benefits
of daily use
4. Non-sporicidal cleaners, used in
conjunction with effective protocol
have been proven to physically
remove a spores and can be
effectively used for daily disinfection of
C. diff rooms in non-outbreak settings.
Healthcare Associated Infection
HAI(p) = HH + ASP + CP + FWM + ED Where:
HAI(p) = Healthcare Associated Infection Prevention
HH = Hand Hygiene
ASP = Antibiotic Stewardship Program
CP = Clinical Practices
FWM = Fecal Waste Management
ED = Environmental Disinfection
Questions?
50
References
Alfa MJ, et al. Improved eradication of Clostridium difficile spores from toilets of
hospitalized patients using an accelerated hydrogen peroxide as the cleaning
agent. BMC Infect Dis 2010 http://www.biomedcentral.com/1471-2334/10/268
Assessed June 27, 2016
Alfa MJ, et al. Use of a daily disinfectant cleaner instead of a daily cleaner
reduced hospital-acquired infection rates. AJIC 2015;43:141-6
Carling PC, et al. Improving Cleaning of the Environment Surrounding Patients
in 36 Acute Care Hospitals ICHE 2008;29(11):1035-41
References
Centers for Disease Control. Options for Evaluating Environmental Cleaning.
2010 http://www.cdc.gov/HAI/toolkits/Evaluating-Environmental-Cleaning.html
(assessed on June 27, 2016)
Dubberke ER, et al. Strategies to prevent Clostridium difficile Infections in acute
care hospitals: 2014 update. ICHE 2014;35(6):628-45
Greater New York Hospital Association. Reducing C. difficile infections toolkit:
Best practices from the GNYHA/UHF collaborative. Accessed online May 27,
2016. http://gnyha.org/resourcecenter/?catid=55&typeid=94
Rutala W, et al. Selection of the ideal disinfectant. ICHE 2014;35(7):855-65
References
Rutala WA, et al. Efficacy of different cleaning and disinfection methods against
Clostridium difficile spores: importance of physical removal versus sporicidal
inactivation. ICHE 2012;33(12):1255-8
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