Infection Control Report

Rutala, WA, et al. (2019) Infection Control & Hospital Epidemiology 40(3): 380-382.

Candida auris is an emerging fungal pathogen that is often resistant to major classes of antifungal drugs. It is considered a serious global health threat because it can cause severe infections with frequent mortality in more than a dozen countries. It can survive on healthcare environmental surfaces for at least 7 days and can cause outbreaks in healthcare facilities. In this study, we investigated 12 different disinfectants (ie, 8 low- and intermediate-level disinfectants in 2 dilutions of sodium hypochlorite and 5 high-level disinfectants/chemical sterilants) and 9 antiseptics commonly used in healthcare facilities for their antimicrobial activity against C. auris and C. albicans.

Chen, LF, et al. (2019). Infection Control & Hospital Epidemiology 40(1):47-52.

Microbiological Bacterial Transfer events between patients and the environment were obsrved in 18.5% of patient encounters and occurred early in the admission. This study suggests that research on prevention methods beyond the standard practice of room disinfection at the end of a patient’s stay is needed to better prevent acquisition of MDROs through the environment.

Munoz-Price LS, et al. (2019). Infection prevention in the operating room anesthesia work area. Infection Control & Hospital Epidemiology 2019, 40, 1-17.

A growing body of literature has shown contamination in the anesthesia work area, including the anesthesia medical work cart, stopcocks, laryngeal masks and laryngoscope blades, touchscreens, and keyboards, as well as on providers’ hands, resulting in transmissions, healthcare-associated infections, and increased risk of patient mortality. This guidance provides recommendations specific to the anesthesia work area to improve infection prevention through HH, environmental disinfection, and implementation of effective improvement efforts.

Huang, SS, et al. (2019) Lancet. 393(10177)1205-1215

Universal skin and nasal decolonisation reduces multidrug-resistant pathogens and bloodstream infections in intensive care units. The effect of universal decolonisation on pathogens and infections in non-critical-care units is unknown. Decolonisation with universal chlorhexidine bathing and targeted mupirocin for MRSA carriers did not significantly reduce multidrug-resistant organisms in non-critical-care patients.

Huang SS, et al. N Engl J Med. 2019 Feb 14;380(7):638-650.

Hospitalized patients who are colonized with methicillin-resistant Staphylococcus aureus (MRSA) are at high risk for infection after discharge. Postdischarge MRSA decolonization with chlorhexidine and mupirocin led to a 30% lower risk of MRSA infection than education alone.

Each quarter, we will select from the best journal articles practical, evidence-based science that you can apply to your work in your health care setting.

by William A. Rutala, PhD, MPH,¹  and David J. Weber, MD, MPH^{1, 2}

In 2014, we published a paper on the “Selection of the Ideal Disinfectants”.¹ Disinfectant selection (i.e., disinfectant product) is one of the two essential components for effective disinfection. The other component, the practice, is the thorough application of the disinfectant such that the disinfectant contacts all contaminated surfaces.  In addition, there should be proper training of hospital staff (especially environmental services and nursing) and use of an EPA-registered disinfectant active against the concerning microbes (e.g., sporicidal agent for Clostridium difficile). The combination of “product” and “practice” results in effective surface disinfection and leads to the reduction of patient risk and improved patient outcomes.^{1, 2}  One of five key considerations in the selection of an ideal disinfectant is commonly referred to as the “contact time”.¹ The purpose of this paper, which was recently published, is to provide a better understanding of “contact time” for liquids and “treatment time” for disinfectant wipes and sprays.³

The method that has been used for over 60 years for EPA registration of liquid and dilutable liquid disinfectants for hard surfaces is the Association of Official Analytical Chemists (AOAC) Use-Dilution Method.  In brief, this is performed by immersing stainless steel carriers in bacteria (e.g. Staphylococcus aureus), treating them with the disinfectant for a prescribed time, and then placing the carriers in growth media to determine if there are any surviving bacteria.⁴ With this test, all microbes on a carrier (e.g., ≥1,000,000 S. aureus on a stainless steel carrier) must be inactivated to result in a negative carrier.  If ≥1 organism survives, the carrier is positive and you must have nearly all carriers negative (e.g., performance standard for S. aureus is 0-3 positive carriers out of 60) to support EPA registration.  This method is a qualitative test (i.e., pass/fail based on any bacterial growth) rather than a quantitative method (e.g., determines the log₁₀ reduction such as 5-log₁₀ reduction in 1 minute). Thus, this Use Dilution test measures the ability of the disinfectant to inactivate the test organism (normally about 10⁶ test organisms per carrier) in the disinfectant in a measured time.

[Read more…] about Surface Disinfection: Treatment Time (Wipes/Sprays) versus Contact Time (Liquids)

by William A. Rutala, PhD, MPH, David J. Weber MD, MPH

Carbapenem-resistant Enterobacteriaceae (CRE) have broad resistance to most β-lactam antibiotics and are a growing worldwide problem. CRE infections are difficult to treat, have a substantial mortality, and are involved in healthcare-associated outbreaks via contaminated environmental surfaces and medical equipment. Colistin-resistant Enterobacteriaceae carrying the mcr-1 gene are a global health concern since colistin is often a last-line antibiotic used to treat CRE. Furthermore, a recent study from China described a hospital outbreak caused by MCR-1-producing Klebsiella pneumoniae with potential spread of mcr-1 via the hospital environment.

Although there is currently no strong scientific evidence demonstrating that clinical use of disinfectants/antiseptics is associated with selection of antibiotic-resistant organisms, some studies have described reduced susceptibility to disinfectants (e.g., quaternary ammonium compounds [QAC]), antiseptics (e.g., chlorhexidine), and cross-resistance (e.g., benzalkonium chloride/quinolones). Susceptibility to germicides (e.g., disinfectants, antiseptics) for carbapenem- or

colistin-resistant Enterobacteriaceae is poorly described. Kanamori et al recently published a paper on the efficacy of multiple germicides against these emerging antibiotic-resistant pathogens using a disc-based quantitative carrier test method.

The efficacy of germicides with active ingredient, product name, and classification against test organisms is summarized in Table 1. Overall, most germicides reached at least 3-log₁₀ reduction (20/22 [91%] for KPC-K. pneumoniae, 22/22 [100%] for KPC-E. cloacae, 18/22 [82%] for KPC-E.coli, 19/22 [86%] for MCR-1-E. coli). Furthermore, all germicides, except for two products (1% chlorhexidine gluconate plus 61% ethyl alcohol and 3% hydrogen peroxide) against MCR-1-E. coli, demonstrated at least 2-log₁₀ reduction for these pathogens even in challenging test conditions (5% FCS and 1 minute exposure time).  Given that hospital environmental surfaces generally have <2-log₁₀ organisms/cm², this level of kill is likely sufficient for use as a surface disinfectant. Thus, these study results demonstrated that germicides commonly used in healthcare facilities likely will be effective against carbapenem/colistin-resistant Enterobacteriaceae when used appropriately. See Table 1 next page. [Read more…] about Germicidal Activity against Carbapenem/Colistin-Resistant Enterobacteriaceae

by Evelyn Cook, RN, CIC

National Healthcare Safety Network’s (NHSN) Multidrug-Resistant Organism and Clostridium difficile Infection (MDRO/CDI) Module, define CDI-positive laboratory assay as:

• A positive laboratory test result for difficile toxin A and/or B, (includes PCR and/or toxin assays) tested on an unformed stool specimen; OR

• A toxin-producing difficile organism detected by culture or other laboratory means performed on an unformed stool sample.

The NHSN Patient Safety Component-Annual Hospital Survey requires facilities to indicate the primary testing method for C. difficile, used most often by your facility’s laboratory (or by the outside laboratory where your facilities testing is performed). Additionally, when facilities complete the “MDRO/CDI Prevention Process and Outcome Measures Monthly Reporting” form for the last month of each quarter, users are asked to report the primary type of test that was used to identify CDI in the facility for that quarter.

NHSN uses that test type in the calculation of the Standardized Infection Ratios (SIRs) for C. difficile for that quarter.

A variety of diagnostic tests, used to identify C difficile, are available and testing methods may vary significantly between healthcare facilities.  A number of facilities are now using multi-step testing algorithms such as:

• NAAT plus EIA (2 step algorithm)
• GDG plus EIA (2 step algorithm)
• GDH plus EIA for toxin, followed by NAAT for discrepant results

In 2017, all specimens that tested positive for C. difficile were reported to NHSN and SIRs were calculated based on quarterly testing methodology. Refer to example below:

[Read more…] about Diagnostic Test for C difficile: Does It Matter?

by Katie Steider, MPH, CPH

(reprinted from NC SHARPPS Program Newsletter)

Phase 2 of the revised Medicare and Medicaid requirements for participation for long-term care facilities (LTCFs) (42 CFR part 483, subpart B) went into effect November 28, 2017. These requirements include the minimum health and safety standards that LTCFs must meet to participate in Medicaid and Medicare. Phase 2 revisions include the requirement for LTCFs to communicate specific information to a receiving provider (e.g. at an acute care hospital) when a resident is transferred or discharged (§483.15(c)(2)). Although the revisions are specific to LTCFs, hospitals should also be aware of the new requirements as they may see changes in communication from LTCFs. These revisions are an opportunity for all healthcare facilities to evaluate their existing interfacility communication methods to assess the information that is included.

The LTCF requirement for interfacility communication includes, but is not limited to, isolation precaution information due to current or previous infection/colonization, most recent relevant labs, medications (including when last received), advance directive information, and comprehensive care plan goals. In order to facilitate this communication between healthcare settings, the NC Division of Public Health Surveillance for Healthcare Associated and Resistant Pathogens Patient Safety (SHARPPS) Program developed and piloted an interfacility transfer form. The form contains the information necessary for LTCFs to be in compliance with the revised Medicare and Medicaid requirements as they relate to communication to a receiving provider at transfer and discharge.

Pilot participants from an acute care hospital, emergency medical services, and LTCFs reviewed the form favorably. Participants reported the form was useful for identifying individuals on isolation precautions and identifying appropriate personal protective equipment (PPE); initiating isolation precautions in the emergency department; preparing PPE in the ambulance; and identifying individual needs and baseline status. Participants also reported that using a standard interfacility transfer form county-wide was beneficial in communicating information clearly and efficiently between different healthcare facilities. This collaborative approach to interfacility communication reflects CDC recommendations for managing multidrug-resistant organisms in healthcare settings and combating antibiotic resistance. The NC SHARPPS Program encourages any efforts to standardize interfacility communication between healthcare facilities and collaboration to contain and prevent multidrug-resistant organisms.

The interfacility transfer form and instructions are available free of charge from the NC SHARPPS Program webpage. Please email nchai@dhhs.nc.gov with questions or for more information.

From UNC Health Care and UNC School of Medicine Vital Signs, November 30, 2017

Karen Hoffmann, RN, BSN, MS, CIC, FSHEA, FAPIC, has been elected to serve as President Elect of the Association of Professionals in Infection Control and Epidemiology, a position she will hold through January 2019, at which time she will become APIC president. Hoffmann has served as a clinical instructor in the Division of Infectious Diseases since 1988. The Association for Professionals in Infection Control and Epidemiology (APIC) is the leading professional association for infection preventionists (IPs) with more than 15,000 members. It’s mission is to create a safer world through the prevention of infection.

From the APIC Website:

Karen Hoffmann, RN, MS, CIC, FSHEA, FAPIC has served as the Clinical Instructor in the Division of Infectious Diseases at the University of North Carolina’s School of Medicine in Chapel Hill since 1988. Under a contract between UNC and the Centers for Medicare and Medicaid (CMS), Karen also currently serves as the infection preventionist for the CMS Survey and Certification Group.Karen has specialized in infection control and prevention for over 30 years, beginning at the Detroit Medical Center, then at the University of Virginia Hospitals, and for 23 years as the Associate Director and consultant for the North Carolina Statewide Program for Infection Control and Epidemiology (SPICE). She has served her local APIC-NC chapter in numerous elected and committee positions, and currently is the immediate-past Chair on the APIC Annual Conference Committee. Karen is a Fellow in the Society of Healthcare Epidemiology of America (SHEA). In 2010 she received the SHEA “Advance Practice Infection Preventionist Award”. Karen served on the SHEA journal, Infection Control and Healthcare Epidemiology, editorial board from 1991 to 2011. She has been an invited speaker to state, national, and international conferences and has authored several abstracts, articles, and book chapters. She was the first recipient of the Infection Control Today, “Infection Control Educator of the Year” award.

Ms. Hoffmann earned her Bachelor of Science degree in Nursing from Indiana University and her Master of Science degree in Healthcare Epidemiology from the University of Virginia. She has been certified in infection prevention and control since 1989.