INFECTION TRANSMISSION IS A CONTACT SPORT. Presented by: Kim H. Neiman MPH, BSN, RN, CIC

Transcription

1 INFECTION TRANSMISSION IS A CONTACT SPORT Presented by: Kim H. Neiman MPH, BSN, RN, CIC

2 DISCLOSURE I am a paid employee of the clinical team of PDI Healthcare. The content of this presentation is not representative of the views of PDI or its ownership. There will be NO discussion of any PDI products and/or solutions in accordance with CE Requirements. Presentation will incorporate best practices from a variety of information sources that bridge medical disciplines.

3 AFFILIATIONS Member of the Association for Professionals in Infection Control and Epidemiology (APIC) Member of APIC Southern Nevada and APIC Sierra chapters Member of the Northern Nevada Infection Control (NNIC) network Member of the Infusion Nurses Society (INS) Member and Industry partner of the Association for Vascular Access (AVA)

4 PROGRAM OBJECTIVES Understand the role of surface disinfection in healthcare today Describe recommendations for special pathogens Discuss current disinfection & prevention technology and factors to consider when choosing disinfectants

5 IS INFECTION TRANSMISSION A CONTACT SPORT? Patient(s) contaminate surfaces or medical equipment Environmental surfaces/inanimate objects are reservoirs (fomites) Healthcare workers contact contaminated surface & patients Environmental Contamination + Poor Hand Hygiene Contributes to the spread of resistant pathogens

6 THE DIRTY DOZEN Kitchen Sink Airplane bathrooms Wet laundry Public drinking fountains Shopping cart handles ATM buttons Women s purse Playgrounds Health club (mats/machines) Your bathtub Office telephone Hotel Room Remote

7 HIGH TOUCH SURFACE CLEANING EVALUATION Figure 1. Overall percentage of high risk objects determined to have been cleaned in each of the 23 acute care hospitals ICHE (1):1 7

8 FREQUENCY OF WORKER CONTACT OF CONTAMINATED ENVIRONMENTAL SURFACES ICHE 2010, 31:

9 UNDERSTANDING REGULATIONS WHAT DOES THIS MEAN TO YOU? 0

10 EPA CATEGORY - DISINFECTANTS DISINFECTANT: an agent that destroys or irreversibly inactivates infectious or other undesirable bacteria, pathogenic, or viruses, but not necessarily bacterial spores, on surfaces or inanimate objects EPA registers three types of disinfectant products based upon submitted efficacy data LIMITED DISINFECTANT: Agent limited to either grampositive or gram-negative microorganisms. Example: Pine oil toilet bowel products effective against gramnegative bacteria GENERAL OR BROAD SPECTRUM DISINFECTANT: Agent that is effective against both gram-positive and gramnegative bacteria Most household disinfectants and disinfectants for swimming pools and water purifiers

11 EPA CATEGORY - DISINFECTANTS HOSPITAL DISINFECTANT: An agent effective against: Gram negative organism (Salmonella choleraesuis) Gram positive organism (Staphylococcus aureus) Pseudomonas aeruginosa Contains certain claims that it destroys or eliminates all forms of microbial life in the inanimate environment, including all forms of vegetative bacteria, bacterial spores, fungi, fungal spores, and viruses Used in all healthcare facilities Virucide claim: product must be effective against specific virus the company wishes to list on label Tuberculocide claim: product must be effective against a Mycobacterium that EPA accepts as a surrogate for the actual tuberculosis bacterium Fungicidal claim: product must be effective against Trichophyton mentagraphites

12 EPA CATEGORY - DISINFECTANTS SANITIZER: Agent that reduces, but does not necessarily eliminate, the microorganisms in the inanimate environment to levels considered safe by public health codes or other regulations EPA registers many sanitizers i.e., non food contact surfaces, food contact surfaces Performance standard for food contact surfaces is % (5-log reduction) within 30 sec Performance standard for non-food use sanitizer is 99.9% (3-log) reduction in 5 min

13 KILL CLAIMS VS. CONTACT TIMES KILL CLAIM: Defined when a disinfectant product is tested to have 100% efficacy against a specific organism at a determined contact time; and the testing data has been accepted by the EPA Bridging of Data for Label Claims What does this mean? Similar product application

14 KILL CLAIMS VS. CONTACT TIMES CONTINUED Contact Time: The time needed for the germicide solution to remain wet on the surface to achieve disinfection of the stated kill claims on the manufacturer s label General directions for use: requires manufacturers to place highest contact time in those directions. Special Instructions for Bloodborne Pathogens may include special directions such as lower contact time for targeting these organisms (e.g. HIV, HBV, HCV).

15 MECHANISM OF ACTION - DISINFECTANT SURFACE DISINFECTANTS Disinfectants typically have a positive charge Gram-negative bacteria typically have a negative charge Disinfectant is drawn to the bacteria Disinfectant Gram negative bacilli Disinfectant then Attacks and adsorbs through the cell wall disrupts the cell membrane which release potassium ions and other cell components Results in cell death Gram neg baci ative lli Block, Fifth Edition

16 CONTACT TIME Disinfect noncritical surfaces with an EPAregistered hospital disinfectant using the label s safety precautions and use directions. Most EPAregistered hospital disinfectants have a label contact time of 10 minutes. However, many scientific studies have demonstrated the efficacy of hospital disinfectants against pathogens with a contact time of at least 1 minute. By law, the user must follow all applicable label instructions on EPAregistered products. If the user selects exposure conditions that differ from those of EPA-registered products label, the user assumes liability for any injuries resulting from off-label use and is potentially subject to enforcement action under FIFRA Rutala, W. Disinfection, Sterilization and Antisepsis Principles, Practices, Current Issues, New Research, & New Technologies. APIC Conference Proceedings, 2010 Ed. Pg 9

17 INFLUENCING FACTORS FOR DISINFECTION EFFICACY Cleaning of object Bioburden (organic or inorganic load present) Type and level of organism contamination Concentration of product Exposure time Nature of object Temperature and relative humidity

18 DISINFECTANTS USED IN HEALTHCARE* (INTERMEDIATE-LOW LEVEL) Phenolics Quaternary ammonium compounds Iodophors Alcohols Chlorine and chlorine compounds Combination e.g., Alc/Quat Hydrogen peroxide Disinfectants are not interchangeable. Select an appropriate disinfectant for any item and use. Caution: some disinfectants may cause respiratory breathing problems (e.g. chlorines)

19 APPROACH TO DISINFECTION AND STERILIZATION Spaulding s Classification: >30 yrs old CRITICAL ITEMS: High risk of infection sterile tissue SEMI-CRITICAL ITEMS: Contact with mucous membranes or non-intact skin NON-CRITICAL ITEMS: Contact with intact skin (environmental disinfection; inanimate objects)

20 LEVELS OF DISINFECTION STERILIZATION HIGH-LEVEL DISINFECTION: Expected to destroy all microorganisms except high numbers of bacterial spores INTERMEDIATE-LEVEL DISINFECTION: Inactivates Mycobacterium tuberculosis, vegetative bacteria, most viruses, most fungi. LOW-LEVEL DISINFECTION: Can kill most bacteria, some viruses, and some fungi, but cannot be relied on to kill resistant microorganisms such as tubercle bacilli or bacterial spores

21 BACTERIALSPORES MYCOBACTERIUM NON LIPID VIRUSES FUNGI VEGATIVE BACTERIA LIPID VIRUSES Descending Order of Resistance to Germicidal Chemicals. Rutala, W. APIC Guideline for Selection & Use of Disinfectants-1996

22 NEW CONCEPT FOR ORGANISM LIST Difficult Easier Prions Bacterial spores (C. difficile) Protozoan oocysts Helminth eggs Small, non-enveloped viruses (Norovirus) Mycobacteria Protozoan cysts Fungal spores Gram negative bacilli (Acinetobacter, ESBL E. Coli, KPC) Vegetative fungi and algae Large, non-enveloped viruses Gram positive bacilli (MRSA, VRE) Enveloped viruses Weber, DJ. Role of the Environment in the Development of Hospital-Acquired Infection: A Critical Review of the Evidence, ID WEEK, Session 0003.

23 PATHOGENS OF CONCERN

24 VIRUSES NON-ENVELOPED (non-lipid) Generally transmitted by fecal-oral route and contaminated fomites Sturdy Can withstand drying, effects of detergents, extremes of ph, and temperature Can withstand acid environment of stomach ENVELOPED (lipid) Fragile (they require an intact envelop for infectivity) Must remain wet and are spread in: Respiratory droplets, blood, mucus, saliva, and semen Injection organ transplants Murphy, Rosenthal, Pfaller. Medical Microbiology 5 th Ed Chapter 29, pp

25 VIRUSES NON-ENVELOPED (non lipid) Norwalk Virus/Norovirus (Caliciviridae) Adenovirus Rhinovirus Rotavirus Enterovirus Hep A ENVELOPED (lipid) Herpes Simplex HIV CMG Influenza Coronavirus Hep B, C RSV

26 VEGETATIVE BACTERIA MRSA VRE ESBL producing E. Coli; Klebsiella pneumoniae Carbapenem-Resistant Enterobacteriaceae (CRE) Acinetobacter baumanii Pseudomonas aeruginosa E. Coli 0157:H7

27 Clostridium difficile

28 INACTIVATION OF C. DIFFICILE C. difficile spores are more resistant than vegetative cells to commonly used surface disinfectants Environment may be an important source of C. difficile spores Three EPA-registered products specific for inactivating C. difficile spores Recommendations: Use of diluted sodium hypochlorite (1:10 dilution of bleach) in units with high endemic rates and outbreaks 1 1 Rutala, W. Disinfection, Sterilization and Antisepsis Principles, Practices, Current Issues and New Research. APIC Conference Proceedings, Page

29 CLOSTRIDIA DIFFICILE (CONTINUED) 2008 EPA MANDATES EPA has determined all pesticide products that are registered for use against C. difficile must demonstrate efficacious performance against the spore form Vegetative form is not the organism of concern for infection control processes Efficacy testing performed on the vegetative form of the organism will not support a claim for C. difficile spores EPA notified manufacturers with vegetative label claims to remove these claims EPA has developed guidelines to address label claims for C. difficile spores

30 CLOSTRIDIUM DIFFICILE In units with high rates of endemic Clostridium difficile infection or in an outbreak setting, use dilute solutions of 5.25% 6.15% sodium hypochlorite (e.g., 1:10 dilution of bleach) for routine environmental disinfection. Note that there are now EPA registered products available that have claims for C. difficile spores CDC Guidelines for Disinfection & Sterilization

31 CURRENT PRACTICE

32 CDC RECOMMENDATIONS Clean noncritical medical equipment surfaces with a detergent/disinfectant. May be followed by an application of an EPAregistered hospital disinfectant with or without a tuberculocidal claim, in accordance with germicide label instructions Do not use alcohol to disinfect large environmental surfaces Clean and disinfect high-touch surfaces (e.g., doorknobs, bed rails, light switches, and surfaces in and around toilets in patients' rooms) on a more frequent schedule than minimal- touch housekeeping surfaces CDC Guidelines for Disinfection & Sterilization

33 CDC RECOMMENDATIONS FOR SPECIAL ORGANISMS Thoroughly clean and disinfect environmental and medical equipment surfaces on a regular basis by using EPA-registered disinfectants in accordance with manufacturers' instructions Do not use high-level disinfectants (i.e., liquid chemical sterilants) on environmental surfaces; such use is inconsistent with label instructions because of the toxicity of the chemicals Use standard cleaning and disinfection protocols to control environmental contamination with antibioticresistant, gram-positive cocci (e.g MRSA, VRE) organisms CDC Guidelines for Disinfection & Sterilization

34 AHE 2008 & 2012 PRACTICE GUIDELINES Establish cleaning checklists Disinfectants should be applied using pour bottles, not sprays. Never re-immerse cloth (cloth & bucket systems) Cotton decreases efficacy of Quats Establish who cleans what and how EVS Staff Nursing Staff Clean and disinfect as usual for C. diff and then disinfect high touch areas with bleach Understand which products are compatible with equipment Training (new hire, annual, as needed)

35 Approach to Emerging Pathogens Stringent Hand Hygiene Routine Cleaning Daily and Terminal Disinfection Isolation Precautions PPE Prevention General EPA- Registered Disinfectant Pathogen Specific Approach

36 DISINFECTANT SELECTION

37 CURRENT DISINFECTANTS Quaternary ammonium compounds Quaternary/Alcohol formulations Sodium hypochlorite formulations (bleach) Phenolics Hydrogen Peroxide formulation(s) New Technology: Accelerated Hydrogen Peroxide, UV Light, Copper, Silver

38 SELECTING DISINFECTANTS A dilemma for Facilities Many types of equipment and end users Confusion about regulatory compliance (CMS, TJC) IC involvement in product and equipment selection? Focus on Practice or Product or Both? Monitor Practices Education of staff and their involvement in prevention initiatives Who is responsible for cleaning/disinfecting environmental surfaces and equipment?

39 SELECTING DISINFECTANTS CONTINUED Should one disinfectant be used hospitalwide? Medical equipment specifying specific product to use (e.g., IV pumps, Patient Monitoring Equipment) Consider safety and precautionary factors Consider stability and shelf life of product Consider convenience and ease of use

40 GOING GREEN? Hospitals moving toward green initiatives building materials lighting water usage (more efficient toilets, faucets) Insure green initiatives don t inadvertently place infection control and prevention efforts at risk Green cleaners are cleaners not approved for hospital disinfectant Summer 2008 Prevention Strategist (APIC), Finding a Balance.

41 NEW TECHNOLOGY Copper and Silver impregnated materials: Lack of consensus on percentage required for effectiveness Has not been proven to reduce the incidence of HCAIs Automated Room Disinfection Systems: Aim is to improve disinfection, remove/reduce operator reliance, prevent increased risk from prior room occupant UV-C radiation: Use as an adjunctive disinfectant, does not show reproducible significant reduction of bacterial contamination to date, costly. Hydrogen Peroxide Vapor Aerosolization: Improves disinfection, costly, time consuming. Role of Ultraviolet (UV) Disinfection in IC and Environmental Cleaning. Appl Environ Microbiol2013 Feb;79(4): J. O Gorman, H, Humphreys. Application of copper to prevent & control infection. Where are we now? J Hosp infect Aug;81(4): The role of no touch automated room disinfection systems in Infection prevention & control. J. Hosp Infect 2013 Jan;83(1)1-13. Efficacy, efficiency,& safety aspects of hydrogen peroxide vapor & aerosolized hydrogen peroxide room disinfection systems. F.TY et al. J Hosp Infect Mar;80(3):

42 NEW TECHNOLOGY UNANSWERED QUESTIONS Cleaning process before disinfection Room turnover Assessment Cost Responsibility Maintenance and Repair Lifespan F. Barbut et.al. Infect Control Hosp Epidemiol Jun;30(6): TI Fu et.al. J Hosp Infect Mar;80(3): Destrez P. J Hosp Infect Sep; 82(1):68.

43 EVALUATION OF ENVIRONMENTAL CLEANING Improved thoroughness of cleaning results in: Decreased infections (improved patient outcomes) Decreased cost (HAIs often not reimbursable; 1 HAI equivalent to EVS FTE!) Improved patient satisfaction (patients equate dirty rooms with poor care) Meets CMS/TJC requirements Evaluating Checklists

44 PRACTICE MONITORING Visual Assessment: Not a reliable indicator of surface cleanliness Microbiological Methods: What are acceptable results (<2.5 CFUs/cm2 pass?), costly, pathogen specific ATP bioluminescence: Measures organic debris (alive & dead), does not detect viruses, each unit has own reading scale (< RLU), chlorine (bleach) gives false zero reading Fluorescent Marker: Pre-placement of markers is time consuming, punitive, good teaching tool O Sherlock et.al. Is it really clean? An evaluation of the efficacy of four methods for determining hospital cleanliness. J Hosp Infect Jun;72(2): E Brown, et.al. Do surface and cleaning chemistries interfere with ATP measurement systems for monitoring patient room hygiene? J Hosp Infect.2010 Feb;74(2): G. Moore, et.al. The use of adenosine triphosphate bioluminescence to assess the efficacy of a modified cleaning program implemented within an intensive care setting. Am J Infect Control.2010 Oct;38(8): D. Mulvey, et.al. Finding a benchmark for monitoring hospital cleanliness. J Hosp Infect.2011 Jan;77(1): L. Luick, et.al. Diagnostic assessment of different environmental cleaning monitoring methods. Am J Infect Control Aug;41(8):751-2.

45 SUMMARY The environment and fomites play a role in infection transmission thus a contact sport. Understanding the rules and regulations for surface disinfectants, kill claims, contact times and product labels is key to making good choices in selecting disinfectants. In dealing with problem pathogens, understand that it is important to focus on practices & products.

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48 ADDED REFERENCES CDC Guideline for disinfection and sterilization in healthcare facilities., Available at: ov_2008.pdf CDC Guidelines for environmental infection control in healthcare facilities. MMWR 2003:52(RR 10):1-42. Available at: Murphy, Rosenthal, Pfaller. Medical Microbiology 5 th Ed Chapter 29, pp Rutala, W. APIC Disinfection, Sterilization and Antisepsis: Principles, Practices, Current Issues, New Research and New Technologies Edition. Spaulding EH. Chemical disinfection of medical and surgical materials. In: Lawrence C, Block S S, eds. Disinfection, Sterilization and Preservation. Philadelphia: Lea & Febiger, 1968:

49 CONTACT INFORMATION Kim Neiman MPH BSN RN CIC PDI Medical Science Liaison West Region (508)