Emerging Strategies for Control of Multidrug Resistant Organisms in Health Care Environment

Transcription

1 Emerging Strategies for Control of Multidrug Resistant Organisms in Health Care Environment Roy F. Chemaly, MD, MPH, FIDSA, FACP Professor of Medicine Director, Infection Control Director, Antimicrobial Stewardship Program

2 Disclosures Xenex, Inc: Research grant and honorarium

3 Outline Background Impact of MDROs Role of the Environment Emerging strategies for environmental decontamination

4 Why are we so concerned with Multi-Drug Resistant Organisms (MDROs)? MDROs are not necessarily more virulent but: Patient outcomes are worse; higher mortality, LOS and toxicity of alternative antibiotics required Cost per episode of care is increased: Antibiotic cost, LOS, cost of special precautions Antibiotic-resistant infections have been estimated to cost the US healthcare system over $20 billion annually MDROs are transmissible; their presence in some patients poses a risk to other patients

5 Role of the Healthcare Environment Issue: Patients shed important pathogens including VRE, C. difficile, MRSA, and Acinetobacter baumannii into their surrounding environment. Problem: These organisms remain viable on inanimate objects for days to months, and can be transferred from the environment to HCWs hands, and then to other patients. Inadequate Infection Control propagates MDROs. Another problem: Contamination of hospital rooms and equipment can persist despite cleaning and disinfection.

6 Can MDROs be controlled in the hospital?

7 Role of the Healthcare Environment Admission to a room previously occupied by a patient known to be colonized or infected with MDRO increases the chances of acquiring these pathogens. In light of these findings, terminal disinfection following patient discharge should be improved.

8 Challenges in Improving Environmental Cleaning Environmental Services (EVS) has not traditionally been an integral part of the Infection Prevention team Many healthcare institutions run at or near 100% capacity: Room turnover, quick discharge and admission of new patients is a priority Outcome data is not usually shared with EVS staff

9 What has been done? Educational campaigns The use of fluorescent or other markers after cleaning to improve compliance with cleaning regimens Issues: Even aggressive cleaning protocols may not be sufficient to remove contamination with some pathogens The impact of educational campaigns is difficult to sustain.

10 Environmental Cleaning Intervention and Risk of Acquiring MDROs From Prior Room Occupants Setting: ICU rooms The intervention: targeted feedback using a black-light marker, cleaning cloths saturated with disinfectant via bucket immersion, and increased education regarding the importance of repeated bucket immersion during cleaning. Aim: Evaluation of the effect of this intervention on the risk of acquiring MRSA and VRE from prior room occupants. Datta, R. et al. Arch Intern Med 2011;171:

11 Predictors of MRSA and VRE Acquisition Datta, R. et al. Arch Intern Med 2011;171:

12 In Conclusion The thorough environmental cleaning eliminated the increased risk of MRSA acquisition from an MRSA-positive prior room occupant but did not eliminate the increased risk of VRE acquisition from a VRE-positive prior room occupant? Higher burden of VRE contamination in the environment and/or a greater difficulty in eliminating VRE contamination. Datta, R. et al. Arch Intern Med 2011;171:

13 Letter to the Editor Emphasizes on the importance of the environmental route for VRE transmission Potential of reducing VRE acquisition through improved terminal cleaning of VRE isolation rooms by using PX-UV system based on a study that we conducted at MDACC Chemaly RF, et al. Arch Intern Med Oct 10;171(18):

14 Control or Elimination of MDROs in the hospital is a Multidimensional Approach 1. Hand Hygiene 2. Contact Precautions 3. Active Surveillance 4. Education of staff and patients/family 5. Enhanced environmental cleaning 6. Optimal communication between key players 7. Optimize antibiotic use 8. Some might add decolonization

15 Adaptation of New Technologies

16 Enhanced Room Disinfection Systems Automated systems do not rely on the operator to ensure all surfaces are disinfected and adequate contact time is achieved. However, it must be applied in addition to standard cleaning. Require areas to be temporarily vacated of patients and staff and incur additional expense.

17 Hydrogen Peroxide Vapor decontamination HPV to eradicate microorganisms from the environment Source:

18 Flowchart of the patient cohort admitted to any study unit by exposure and intervention. Passaretti C L et al. Clin Infect Dis. 2013;56:27-35

19 Hydrogen Peroxide Vapor decontamination Reduced the risk of MDRO acquisition among high-risk patients when patients are admitted to a room previously occupied by a patient infected or colonized with an MDRO HPV in addition to a thorough infection prevention program could be implemented in high-risk environments to maximize patient safety.

20 Drawbacks The time for disinfection is on average 2 to 4.5 hours. At an average of 15 rooms per day, HPV costs around $ per room

21 Pulsed Xenon Ultraviolet Light (PX-UV) PX-UV produces broad-spectrum UV irradiation, including large amounts of energy in the germicidal spectrum and in the UVA, UVB and visible spectrums using a xenon gas flash lamp. Effective in killing a variety of microbial pathogens, including endospores of C. difficile, vegetative bacteria and viruses. The device is typically operated by housekeeping personnel and includes safety features such as motion sensors. The average operating time is 5 minutes per position for a total of 3 positions based on the average size of each room.

22 Xenon vs. Mercury Xenon Mercury Bulb Type Pulsed Xenon (non-toxic) Mercury (toxic) C. diff kill time 5 minutes 5 min warm up + 45 minutes + 15 minute cool down MRSA kill time 2 minutes 5 min warm up + 45 minutes + 15 minute cool down Effectiveness Published Outcome Studies No Outcome Studies Conducted Intensity High Intensity Low Intensity Spectrum Wide Spectrum* Narrow Spectrum *Xenon emits light across full germicidal spectrum.

23 Evaluation of a PX-UV room disinfection device for impact to hospital operations and microbial reduction at MDACC We compared the use of a PX-UV disinfection system to the standard room terminal cleaning process We assessed the level of room microbial contamination before and after applying each method and the degree to which hospital operations (i.e. room turnaround time) were affected by the use of each approach. Stibich M, et al. Infect Control Hosp Epidemiol Mar;32(3):286-8.

24 Comparison of Room Cleaning Status HPC (cfu/inch) 2 Room Status # of samples # positive (%) min mean median max iqr Pre-clean (77.8) Post Standard terminal clean (57.1) Post PX-UV treatment 19 2 (10.5) Comparison of VRE Positive Surfaces by Room Cleaning Status Room Status # of sample s Phase 1 Phase 2 Combined # (%) of VRE # of samples # (%) of VRE # of samples # (%) of VRE Pre-clean (27.3) 18 2 (11.1) (23.3) Post Standard terminal clean 28 3 (10.7) 21 1 (5.3) 49 4 (8.2) Post PX-UV treatment 56 0 (0) 19 0 (0) 75 0 (0)

25 Hospital Operational Statistics for 8 PX-UV Treated Rooms Activity Minutes PX-UV travel time to room 3:48 Preparing the room :15 PX-UV emittance 12:00 Safety countdown 1:30 Repositioning the PX-UV device :31 Room exit :44 Total PX-UV Disinfection Time 18:48 Stibich M, et al. Infect Control Hosp Epidemiol. 2011; 32(3):

26 In Conclusion The PX-UV system showed a statistically significant reduction in microbial load and eliminated VRE on sampled surfaces when using a 12-minute multi-position treatment cycle At an average of 5 rooms, the cost is $6 per room

27 Equivalency trial of bleach versus PX-UV light for reducing environmental C. difficile contamination on high-touch surfaces in C. difficile isolation rooms Arm Observations Mean CFU before Mean CFU after % reduction Bleach % PX-UV % Chemaly RF, et al. Submitted

28 Routine Incorporation of PX-UV after Standard Cleaning of Rooms Previously Occupied by Patients with VRE Infections or Colonizations.

29 Routine Incorporation of PX-UV after Standard Cleaning of Rooms Previously Occupied by Patients with VRE Infections or Colonizations. Unit From 1/12-12/30/12 HA-VRE Infection/1000 pt. days before PX-UV (#) From 1/13 to 9/13 HA-VRE Infection/1000 pt. days after PX-UV (#) p-value Percent Change Leukemia 0.32 (11) 0.44 (12) % SCT 0.55 (15) 0.28 (6) % Unit HA-VRE Colonization/1000 pt. days before PX-UV (#) HA-VRE Colonization/1000 pt. days after PX-UV (#) p-value Percent Change Leukemia 1.98 (68) 1.35 (37) % SCT 2.76 (75) 1.68 (36) %

30 Infections Per 10,000 Pt days Incidence of Nosocomial Infections of C.difficile FY07- FY13 20 FY07 FY08 FY09 FY10 FY11 FY12 FY UCL= _ U= LCL=0 Jan-07 Sep-07 May-08 Jan-09 Sep-09 May-10 Month Jan-11 Sep-11 May-12 Jan-13 Aug-13

31 12 month HA-C. diff incidence; 120 beds Cooley Dickinson Hospital, Northampton, MA Before Xenex 27 Cases (rate: 0.96) After Xenex 53% reduction Rate: 0.45 (p<0.001) 12 Month MRSA incidence; 945 beds Cone Health System, Greensboro, NC Before Xenex 86 cases (rate: 0.37) After Xenex 54% Reduction (rate: 0.17; p<0.004) *1 Device per 60 Beds Levin J et al. Amer J of Infec Control. 2011, 41 (8): *1 Device per 315 Beds Simmons S et al. Journal of Infection Prevention. 2013, 14:172-4

32 Incidence of Nosocomial MDROs Infections at MD Anderson FY11 MDR NI/1000 pt days FY12 MDR NI/1000 pt days p-value FY11 vs. FY12 FY13 # MDR Infx - total MDR NI/1000 pt days p-value FY12 vs. FY13 VRE NS NS MRSA MDR-Ps. aerug NS ESBL-GNB NS NS GNR-MDRnonESBL NS NS CRE NS NS Total MDR Nosocomial Infections

33 Conclusions Continue to refine and improve our process through enhanced and more consistent cleaning, monitoring, and measuring Improve staff awareness through training and accountability We must blend technical knowledge with socio-adaptive skills We must create a vision where prevention of harm, quality and safety is everyone s responsibility

34 Infection Control Preserves, Protects and Defends Director, Roy Chemaly, M.D., M.P.H. (center). To his left are Linda Graviss (Manager), Cecile Arcilla, Polly Williams and Susan Conley. To his right are Sherry Cantu, Kim Nguyen, Cheryl Perego (retired), and Cindy Good.

35 Thank You!