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051015 1 Prof. Dr. Andreas Voss Radboud umc CanisisusWilhelmina 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.
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  • 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.

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    35 hospitals, 56 nursing homes >4000 HCWs from 56 nursing units 13.8 million HH opportuniKes captured via RFRD HH compliance Start of shi_: 42.6% 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

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    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

    environme

    nt

    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

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    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 Bac

    illus me

    gaterium

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    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

    sink, call bubon, bedside table, monitor, telephone, supply cart, door handle, floor

    Results:

    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

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    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 paKents 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

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    ProspecKve study of 39 sterilized T. Bears, one week a_er use: S.aureus, K.pneumoniae, P.aeruginosa, E.coli, Candida spp, Cryptococcus, Aspergillus and others. 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

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    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

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    NDM1-producing E. coli in 2013 Case-Control Study ERCP procedure: OR 78 AnKbioKcs: OR 9

    Cohort Study 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

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    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

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    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

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    Jurke et al. Euro Surveill. 2013;18(36):pii=20579

    MRSA Screenings Paradox = Wer sucht der findet !

    Ftkenheuer et al Lancet 2014, published online Aug 21st

    Ftkenheuer et al Lancet 2014, published online Aug 21st Ftkenheuer 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

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    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

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    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% chlorhexidine70% isopropyl alcohol or 5% povidone iodine69% 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

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    Mim

    oz et a

    l. Lan

    cet p

    ublishe

    d on

    -line

    Sep

    t 18th, 201

    5

    Mimoz et al. Lancet published on-line Sept 18th, 2015

    Use of 2% CHXalcohol 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 CHXalcohol than with povidone iodinealcohol.

    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

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    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

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    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 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

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    RCT of non-emergency cardic surgery in 17 UK centers

    If hemoglobin level

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    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

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