Global Hygiene Strategies for Health Care facilities with ... · • Pawel Grzesiowski, Warsaw, Poland • Marija Gubina, Ljubljana, Slovenia • P, E, M. Haanen, Amsterdam, The Netherlands

Global Hygiene Strategies for Health Care facilities with special regard to chemical

disinfection

Introduction and objective of the symposium

M. Exner,

Topics

• Some historical remarks

• Controversies on disinfection

• Characterisation of infection risks and pathogens and

Emerging risks

• Regulations

• Disinfection strategies

• Objectives of the symposium

Etiology, Concept and Prophylaxis of Childbed Fever -

Systematic Testmethods for the evaluation of the efficacy of

disinfectants

1881

Mitglieder Cholera-Expedition

1883/4 nach Ägypten und Indien

unter Leitung R. Kochs

Disinfection of hands, surfaces and

instruments with Sublimate and

carbolic acid

Home take messages from R. Koch 1881

• Disinfection is not disinfection

• Efficacy of disinfectants is dependend on

• - microorganisms ( spores and non spores )

• - compounds

• - concentration

• - Time

• - Temperature

Topics




Emerging risks

• Regulations



Controversies on surface disnifection in Germany since 2000

Infection control and hospital epidemiology may 2013, vol. 34, no. 5

Understanding and Preventing Transmission of Healthcare-

Associated Pathogens Due to the Contaminated Hospital

Environment David J. Weber, William A. Rutala

• Franz Allerberger, Innsbruck, Austria

• Graham AyIiffe, Birmingham, UK

• Matteo Bassetti, Genova, Italy

• Ilja Braveny, Miinchen, Germany

• Aira Bucher, Oslo, Norway

• Nizdam Damani, Portadown, N. Ireland

• Franz Daschner, Freiburg, Germany

• Markus Dettenkofer, Freiburg, Germany

• Carmen Ezpeleta, Bilbao, Spain

• Petra Gastmeier, Hannover, Germany

• Christine Geffers, Berlin, Germany

• Helen Giamarellou, Athens. GreeceDonald Goldman, Boston, Mass, USA

• Pawel Grzesiowski, Warsaw, Poland

• Marija Gubina, Ljubljana, Slovenia

• P, E, M. Haanen, Amsterdam, The Netherlands

• Irina Haydouchka, Ploudiv, Bulgaria

• Johannes Hubner, Boston, Mass, USA

• Smilja Kalenic, zagreb, Croatia

• Gertie van Knippenberg-Gordebeke, Venlo,

• A, M. H. Kranenburg, Amsterdam, The Netherlands

• Vladimir Krcmery, Bratislava, Slovakia

• Andrea Kropec, Boston, Mass, USA

• Wolfgang Kruger, Tuebingen, Germany

• Sebastian Lemmen, Aachen, Germany

• C. Glenn Mayhall, Texas, USA

• Marlene Meester, Amsterdam, The Netherlands

• Shaheen Mehtar, Tygerberg, South Africa

• Juerg Munzinger, Luzern. Switzerland

• Igor Muzlovic, Ljubljana. Slovenia

• Juhani Ojajarvi, Helsinki, Finland

• Henning Ruden, Berlin, Germany

• Geoff Scott, London. Great Britain

• Pramod Shah, Frankfurt, Germany

• Arjana Tambic-Andraszevic, zagreb, Croatia

• Klaus Unertl, Tiibingen, Germany

• Andreas Voss, Nijmegen. The Netherlands

• Klaus Weist, Berlin, Germany

In conclusion, there are insufficient scientific data

to support the strong recommendation to routinely

disinfect environmental surfaces in health care

facilities except in certain high risk areas (e.g., isolation

units) or possibly to prevent transmission of

high-risk organisms (e.g., MRSA, VRE).

2002

Schülke Foundation and surface disinfection

Topics




Emerging risks

• Regulations



Characterising the infection risk

Pathogenicity and virulence

• Pathogenicity: the property of an agent that determines the extent to

which overt disease is produced in an infected population.

• The virulence or pathogenicity of an infective agent is the capacity of

an infectious agent to enter the host, replicate, damage tissue, and

cause disease. Virulence describes the severity of clinical disease and

may vary among strains of the same agent.

• Agents of primary pathogenicity:

• Agents of facultative pathogenicity:

• Agents of opportunistic pathogenicity: Agents that almost

exclusively produce infections in persons who are

immunocompromised.

15

Pathogenicity and virulence

• Pathogenicity and virulence require more than just an

organism with the potential to do harm;

• the manifestations of harmfulness demand a singular,

particular host unable to respond in the normal fashion to

microbial activities at that particular time and in that specific

environment.

• In other words, it is a specific host that is the major

determinant of the overt clinical manifestations of infectious

disease.

• “Preventive and Therapeutic efforts must be directed at

restoring a tolerable host-parasite equilibrium”. (HENRY D.

ISENBERG, 1988 )

Primary pathogens

• Primary pathogen: a pathogen which has an inherent

ability to breach the host anatomic, cellular or biochemical

barriers that ordinarily restrict other microbes and prevent

entry by other microorganisms into sterile tissue sites, that

is, "to go where others cannot",

• whereas the facultative or opportunist requires some

underlying defect or alteration in the host defences –

whether it be genetic, ecologic or caused by underlying

disease – to establish itself in usually privileged host

niches.

Vibrio cholerae

Ebola and Disinfection

Ebola and disinfection

• CDC proposes research agenda

CDC 2015 – Ebola as trigger for a re-

evaluation of disinfectants • CDC proposes research agenda focused on the cleaning and

disinfection of surfaces in patient rooms

• In the 1970s and 1980s the transmission of pathogens from healthcare

surfaces to susceptible patients was thought to be insignificant.

• More recent studies show surfaces in the patient’s room such as

bedrails, bedside tables and call buttons may play a role in the

transmission of disease from one patient to another patient.

• However there is limited evidence guiding facilities on the best

practices for preventing or reducing the contamination of these

environmental surfaces.

• On September 14, 2015, CDC’s Division of Healthcare Quality

Promotion (DHQP) hosted the roundtable discussion, “Environmental

Hygiene for Ebola and Other Emerging Pathogens in Healthcare.”

Swine fever and disinfection

Desinfektion und Jagd

Schmidt kündigt Verschärfung der

Schweinepest-Verordnung an

Facultative and opportunistic pathogens

• Agents of facultative pathogenicity: Agents

requiring for disease producing infections specific

prerequisites such as skin lesions, wounds or

medical devices on normally sterile areas of the

body, such as catheters or other foreign bodies,

even in persons who are not immunocompromised

like P. aeruginosa or Legionella spp.

• Agents of opportunistic pathogenicity: agents

that almost exclusively produce infections in

persons who are immunocompromised like

Aspergillus

22

Antibiotic resistance

Facultativ pathogens and environment

• Dry surfaces :

• - MRSA

• - VRE

• - Acinetobacter spp.

• - Clostridium difficile

• - Norovirus

• - molds

• Wet reservoirs

• - P.aeruginosa

• - Klebsiella spp., Serratia spp.

• - Enterobacter cloacae

• - Acinetobacter

Facultative waterborne pathogens

• Legionella pneumophila

• P. aeruginosa

• Coliforms ( Enterobactericeae )

• Antibiotic resistant bacteria

• Non tuberculous mycobacteria ( MOTT) (Mycobacterium

chimerae)

• Acinetobacter spp.

• Others (e.g. Stenotrophomonas, Burkholderia)

25

Common ecologic properties of facultative

pathogens

• Aquatic

microorganisms

• Biofilm build up

• Disinfection tolerance

• Re- growth

• VBNC

• Ultramicrocells

Assessing the Risk of Infection

Concentration of pathogen x Virulence x Antibiotic resistance x

tenacity

--------------------------------------------------------

Specific vulnerabilty or Immunstatus of the host

( predisposition )

Modified from Duncan and Edberg,S.C. 1995, Crit. Rev. Microbiol,

21,85-100

Criteria

Pathogens

• Persistence

• Tenacity

• Infection dose

• Disinfection tolerance

Agents

• Compounds

• Time

• concentration

Outcomes reported in all primary

studies of disinfection, monitoring,

and implementation

Pathogens studied in all primary

studies of disinfection, monitoring,

and implementation

Evidence needs for future research in

environmental cleaning.

Conclusion

• Comparative-effectiveness studies directly comparing disinfection

modalities and monitoring strategies are limited.

• Future research should examine and compare newly emerging

strategies, such as peracetic acid, hydrogen peroxide wipes, enhanced

coatings, and microfiber cloths as cleaning strategies, and adenosine

triphosphate and ultraviolet light technologies as monitoring strategies.

• Patient colonization and infection rates should be included as

outcomes when possible.

• Other challenges to be addressed include identification of surfaces

posing the greatest risk of pathogen transmission, developing standard

thresholds for defining cleanliness, and using methods to adjust for

confounders such as hand-hygiene practices when examining the

impact of disinfection modalities.

• Conclusion—The

outbreak of “Colistin” pan

drug-resistant

Pseudomonas aeruginosa

was caused by a

contaminated

bronchoscope and was

terminated by the

implementation of a

revised disinfection

protocol for

bronchoscope.

Summary of the strategies for environmental cleaning

and disinfection of patient areas.

Topics




Emerging risks

• Regulations



EU Biocidal Product Regulation

Topics




Emerging risks

• Regulations



Chemical Disinfectants

• Alcohol

• Chlorine and Chlorine Compounds

• Formaldehyde

• Glutaraldehyde

• Hydrogen Peroxide

• Iodophors

• Ortho-phthalaldehyde (OPA)

• Peracetic Acid

• Peracetic Acid and Hydrogen Peroxide

• Phenolics

• Quaternary Ammonium Compounds

• Metals as Microbicides

• Ultraviolet Radiation (UV)

Disinfection - The relative effectiveness of

chlorine against different types of

microorganisms

Disinfection Wipes

Dr. Jürgen Gebel, Verbund für Angewandte Hygiene e.V.

Institut für Hygiene und Öffentliche Gesundheit, Universitätsklinikum

Bonn

44

• Krankenhäuser

• Ärztliche und zahnärztliche Praxen

• Alten- und Pflegeheime

• Küchen in Gesundheitseinrichtungen

• Produktionsbetriebe

• Wäschereien

• Öffentliche Einrichtungen (Kindergärten,

Schulen, Bäder, Saunen)

• Friseure

• Tätowierer

• Kosmetik

• Fußpflege

• Haushalte

Anwendungsbereiche der

VAH-Liste

Dr. Jürgen Gebel, Verbund für Angewandte Hygiene e.V.

Institut für Hygiene und Öffentliche Gesundheit, Universitätsklinikum

Bonn

45

Desinfektionsmittel-Kommission

18 Mitglieder:

Dr. Christiansen, PD Dr. Eggers, Prof. Eikmann, Prof. Exner, Dr. Gebel, Dr. Gemein, Dr. Gleich, Prof. Heeg, Prof. Hingst, Dr. Hunsinger, Prof. Kramer, Prof. Martiny, PD Dr. Pitten, Dr. Steinmann, PD Dr. Suchomel, Prof. Vossebein, Prof. Wendt, Prof. Wolff

6 Gäste:PD Dr. Brandt (DGHM) Dr. Burghardt (BW)Frau Jacobshagen (BfArM)Dr. Schwebke (RKI)Prof. Truyen (DVG)Dr. Uhlenbrock (BAuA)

Topics




Emerging risks

• Regulations



Topics

• Historical remarks


• Emerging risks

• Regulations


• Objectives

Introduction and objective of the

symposium

• Overview of disinfection strategies in health care settings in

different countries

• Overview of disinfection strategies in veterinary industries

• Disinfection in time of global spreading of antibiotic

resistance

• Disinfection in time of global interdepencies

• Disinfection in time of Biocidal Product Regulation

• Selection aspects of pathogens

• Where and when do we need disinfection versus cleaning

• Wipes as a new method for surface disinfection

• Antibiotic resistant pathogens ( selection effect and/ or

antibiotic resistance promotion ? )

• Test methods for spores ( eg. Clostridium diff. ) and viruses

( e.g. norovirus )

• Listing of efficient disinfectants by independent institutions

• Disinfection aspects in sewage in medical facilities

• A global understanding of testing and listing of disinfectants

• Research needs

Hygiene-Institut

der Universität

Bonn

Hospital Hygiene in

Nigeria

Water, sanitation and Hygiene in a hospital

in Nigeria

Global Hygiene Strategies for Health Care facilities with special regard to chemical

disinfection

Introduction and objective of the symposium

M. Exner,

Institut für Hygiene und Öffentliche Gesundheit

der Universität Bonn

Umfeld Kontamination mit Carbapenem- resistenten

Enterobacteriaceen – Lerner et al. 2013



Schematische Darstellung des

Wischverfahrens

1 2 3 4

Cleans

ing

mop



Vergleichende Untersuchung zur Wirksamkeit

von Reinigungs-und Desinfektionsverfahren auf

S.aureusWasser

Tenside

Glykol Derivate & Quats

100.000

10.000

1.000

100

10

1

5

4

3

2

1

0

Re

du

kti

on

s F

aK

tor

Alkylamine

Aldehydes

Peroxides

100.000

10.000

1.000

100

10

1

100.000

10.000

1.000

100

10

1

5

4

3

2

1

0

5

4

3

2

1

0

KB

E /

25

cm

²

Feld 1 Feld 2 Feld 3 Feld 4 Feld 1 Feld 2 Feld 3 Feld 4

Global Hygiene Strategies for Health Care facilities with ... · • Pawel Grzesiowski, Warsaw, Poland • Marija Gubina, Ljubljana, Slovenia • P, E, M. Haanen, Amsterdam, The Netherlands

Documents