Dirty Stories:infection control

under a media spotlightDr Mike Simmons

Office of the Chief Medical Officer

Rapid Review Panel

The Rapid Review Panel (RRP) has been convened by the HPA at the request of The Department of Health.

Rapid Review Panel

The panel provides a prompt assessment of new and novel equipment, materials, and other products or protocols that may be of value to the NHS in improving hospital infection control and reducing hospital acquired infections.

Rapid Review Panel

The panel will not conduct evaluations of products but will review information and evidence provided and make recommendations to the Department of Health.

Recommendations

1. Basic research and development, validation and recent in use evaluations have shown benefits that should be available to NHS bodies to include as appropriate in their cleaning, hygiene or infection control protocols.

Recommendations

2. Basic research and development has been completed and the product may have potential value; in use evaluations/trials are now needed in an NHS clinical setting.

Recommendations

3. A potentially useful new concept but insufficiently validated; more research and development is required before it is ready for evaluation in practice.

Recommendations

4. Unlikely to be of benefit OR not a significant improvement on equipment/materials/products already available which may contribute to reducing health care associated infection; no further consideration needed.

Recommendations

5. Insufficient clarity/evidence presented to enable full review of the product.

Recommendations

6. An already well established product that does not merit further consideration by the Panel.

Recommendations

7. The product is not sufficiently related to infection control procedures to merit consideration by the Panel

Disinfection Statement

Companies are advised that the Rapid Review Panel will not evaluate disinfectant products that have not demonstrated improved in vitro disinfection activity when compared with appropriate established disinfection products.

Products with similar disinfection properties would need to show major clinical advantages over existing products to be considered.

The Hospital Environment

The hospital environment is commonly perceived as a more important source of infection than evidence suggests. Walls and ceilings are rarely implicated in cross-infection, provided the surface remains intact and dry. In addition the consensus view is that there is little evidence microbes on general surfaces play any role in the transmission of healthcare associated infections.

Vaporised Hydrogen Peroxide

The key question is whether the ability of hydrogen peroxide vapour to kill environmental micro-organisms will translate into reduced numbers of healthcare associated infections.

Greenbridge Environmental Control Ltd: D-STROY

Antimicrobial synergy is claimed although no evidence in the literature is advanced. Supplied data demonstrate disinfectant level activity against a spectrum of organisms, with some beneficial antiviral capabilities.

Isis Envoshield

There seems little doubt that this compound would be effective as a surface decontaminant. Further evidence from field studies is required to demonstrate superior in-use efficacy over other products and procedures.

ChloraPrep

Supporting data of the product’s efficacy is comprehensive and includes a number of published reports in the Journal of Infusion Nursing, British Journal of Infection Control, Journal of Clinical Microbiology, Journal of Bone & Joint Surgery, Infection Control and Hospital Epidemiology and the Journal of Hospital Infection attesting to its performance. This product is likely to support the reduction of central-line associated blood stream infections.

Supporting Data

• Is there evidence that use of a product leads to reduced healthcare associated infection?

• Is there evidence that the environmental contamination can be reduced by use of a product?

Vancomycin Resistant EnterococciEnvironmental contamination

• Found in 7 - 37% of environmental samples

• More common if patients have diarrhoea

• Nurses gowns found contaminated• 8% of cultures positive even after

terminal cleaningBoyce 1994, Montecalvo 1995, Boyce 1995

Environmental Contamination with MRSA

• Burns unit, attack rate 75%– 33 of 145 environmental swabs positive– Hydrotherapy facilities contaminated

• Surgical unit without MRSA problem– 1 of 36 surfaces positive

Crossley 1979

Environmental Contamination with MRSA

• 25 rooms of MRSA positive patients• 53.6% of surface samples positive• 28% of air samples positive• 70% of patient and environment swabs

indistinguishable on typing

Sexton et al Journal of Hospital Infection Feb 2006

Million Dollar Questions

• Does the presence of pathogens in the environment present a risk to patients?

• Are pathogens present as a result of infection?

• If we can remove the environmental organisms will this affect secondary cases?

MRSA airborne spread

• Dust• Intensive Care Unit• MRSA positive patients in side room• Frequent new MRSA

– No previous admissions– Negative on admission– Always in same bed

MRSA airborne spread

• Exhaust ventilation• Hot day in summer• Window by bed opened and access by

air exhausting from side room

Controlled Study 1

• ICU cleaned 3x daily• Two limbed study

– 6 months disinfectant (0.5% aldehyde)– 6 months detergent

• Active surveillance by ICNs• No difference in HAI rates

Dashner Dtsch Med Wschr 1980

Controlled Study 2

• Tertiary centre, 8 wards• Phenolic disinfection vs detergent• 6 months, random selection of wards• Users blind to product used• No difference in HAI rates

Danforth, JHI 1987

Controlled Study 3

• 4 months, large medical centre (2 wings)• Detergent vs. disinfectant (quaternary

ammonium compound or peroxygencompound)

• Environmental cultures undertaken• Measured HAI rates

Dharan, JHI 1999

Results of Study 3

• Bacterial counts increased where detergent only used

• Counts decreased where peroxygendisinfectant used

• No difference in HAI rates• Environmental pathogens not linked to

infections

Dharan, JHI 1999

Clostridium difficile

• Before and after intervention study• 293 patients, 3 units• Hypochlorite for C diff patients• C diff rates in BMT unit reduced

– 8.6 to 3.3 per 1000 patient days– No effect in neuro or gen med patients

Mayfield, CID 2000

Dirty Stories

• Hospitals should be clean• Environmental contamination relates to public

perception more than real risk• Public perception is fuelled by media stories

(and we may only have ourselves to blame)• Environmental contamination can be

substantial in outbreaks• Decontamination can help halt

outbreaks e.g. C diff