Environmental Surveillance FIDSSA 2015 Dr Ben Prinsloo Medical Microbiologist
The Scientist A scientist, in a broad sense, is a person engaging in a systematic activity to acquire knowledge We require evidence WE NEED AN ANSWER
YES / NO
Lunar Distance
Laser ranging retro reflector
Lunar Distance
HCAI
Hand Hygiene Actions
BMC Infectious Diseases 2006, 6:130 Bacterial & Fungal Persistence
Viral Persistence
Age of Resistance VRE, MRSA, CRE, ESBL, C difficile, C parapsilosis Antibiotic resistant pathogens continues to escalate Hayden MK. Clin Infect Dis 2006;42:1552-60
HCAI HCAI is a major problem for patient safety and its surveillance and prevention must be a first priority prolonged hospital stay long-term disability increased resistance of microorganisms to antimicrobials massive additional financial burden
HCAI HCAI concerns 5 15% of hospitalized patients 9 37% of those admitted to intensive care units (ICUs) 25 million extra days of hospital stay Economic burden of 13 24 billion
Housing Challenge 20x15 R300 billion x1000 R300 000 million/150 000 2 000 000 EUR Euro 15.1651409921 0.0659406992 2.68 million houses built by the state since 1994 according to the 20 Year Review. (134 000/year) http://www.sanews.gov.za/southafrica/housing-delivery
The Patient zone The patient zone is defined as the patient s intact skin and his/her immediate surroundings colonized by the patient flora and the healthcare area as containing all other surfaces
My Five Moments for Hand Hygiene
HCAI
Environmental contamination Multidrug-resistant (MDR) Acinetobacter baumannii (MDR-AB) is an important nosocomial pathogen Prospective cohort study of ICU patients colonized or infected with MDR-AB For each patient, 10 surfaces in the patient room were sampled AJIC Volume 39, Issue 9, November 2011, Pages 711 715
Environmental contamination Fifty rooms were sampled 48% (24/50) were positive at 1 or more sites Supply carts (10/50, 20%) Floors (8/50, 16%) Infusion pumps (7/50, 14%) Ventilator touch pads (5/44, 11.4%) Surrounding environment is frequently contaminated AJIC Volume 39, Issue 9, November 2011, Pages 711 715
The Patient zone Patients occupying rooms previously occupied by patients with VRE MRSA, Clostridium difficile, and Acinetobacter baumannii infection or colonization have on average a 73% increased risk of acquiring the same pathogen Infect Control Hosp Epidemiol 2006;27:127-32 Epub February 8, 2006
The Patient zone Only 40% of near patient surfaces are being cleaned in accordance with existing hospital policies Studies have shown thoroughness of disinfection cleaning can be improved to 82% (on average more than 100% over baseline)
Direct Practice Observation Covert monitoring of disinfection cleaning can provide an objective assessment of individual ES staff performance and compliance with cleaning protocols Cleaning improved from 48% to 87% Maintaining such a program
General Principles: Microbiologic Sampling of the Environment Before 1970, US hospitals conducted regularly scheduled culturing of the air and environmental surfaces (e.g., floors, walls, and table tops) During 1970 1975, 25% of US hospitals reduced the extent of such routine environmental culturing
High-touch surfaces The CDC (2003) recommended that hospitals clean and disinfect high-touch surfaces Hospitals monitor (ie, supervise and inspect) cleaning performance Consistent cleaning and disinfection Touched by the patient and health care professionals
Swab Cultures Limited feasibility of monitoring multiple surfaces in multiple patient rooms as part of an ongoing monitoring program
Environmental Surface Sampling Routine environmental-surface sampling (e.g., surveillance cultures) in health-care settings is neither cost-effective nor warranted Environmental surface surveillance can not directly protect a patient from HCAI
1 Support an investigation of an outbreak of disease or infections when environmental reservoirs or fomites are implicated epidemiologically in disease transmission
2 Environmental sampling may be warranted in research
3 Monitor a potentially hazardous environmental condition Presence of a hazardous chemical or biological agent Validate the successful abatement of the hazard
4 Quality assurance to evaluate the effects of a change in infection-control practice or to ensure that equipment or systems perform according to specifications and expected outcomes
Agar Slide Cultures Agar coated glass slides with finger holds were developed to simplify quantitative cultures of liquids Determine pre-cleaning levels of contamination for each object evaluated in order to accurately assess cleaning practice
Fluorescent Markers Surfaces that are effectively disinfected but less effectively cleaned may be more likely flagged as failing to meet a quality standard using one of these markers than one of the culture techniques Disinfection cleaning improving from 48% to 77%
ATP Bioluminescence A specialized swab is used to sample a standardized surface area Total amount of ATP, both microbial and non-microbial, is quantified and expressed as relative light units
Evaluating the Pt Zone
Cleanliness versus cleaning practice Observation and fluorescent gel systems directly evaluate the cleaning process The swab or slide culture as well as ATP bioluminescence systems measure cleanliness Intrinsically low concentration of most major HAPs on surfaces limits the use of pathogen-specific monitoring
ICE
Creepy Crawlies Cockroaches Gram-negative bacteria Acinetobacter spp.; Citrobacter freundii; Enterobacter spp., E. cloacae; Escherichia coli; Flavobacterium spp.; Klebsiella spp.; Proteus spp.; Pseudomonas spp., P. aeruginosa, P. fluorescens, P. putida; Salmonella spp.; Serratia spp., S. marcescens; Shigella boydii Gram-positive bacteria Bacillus spp.; Enterococcus faecalis; Micrococcus spp.; Staphylococcus aureus, S. epidermidis; Streptococcus spp., S. viridans Fungi Aspergillus niger; Mucor spp.; Rhizopus spp. Candida spp. (houseflies)
Conclusions Hand Hygiene Bacterial Persistence of MDR organisms Patient zone Monitoring / Evaluation
Clutter and confusion are failures of design, not attributes of information. Edward Tuft Don t make the process harder than it is. Jack Welch