APSIC Abstracts on Environmental Control

The following abstracts on the topic of environmental control are from the meeting of the eighth International Congress of the Asia Pacific Society of Infection Control (APSIC), held in Bangkok, Thailand, Feb. 12-15, 2017.

Reference: Antimicrobial Resistance & Infection Control. Abstracts from the 8th International Congress of the Asia Pacific Society of Infection Control (APSIC) Volume 6, Supplement 2. February 2017.

E1: Analysis of risk factors among 51 measles patients infected with multiple drug-resistant bacteria

Zhao Xian-li, Li Xiao-long, Yao Xue-hua, Ren Wei, Zhang Xia Zeng

Background
In recent years, we found rising in trends of measles infections, even in a small local epidemic. It may because of the measles virus’ genes per se, antigenic variation or other factors. Infected with measles virus can cause temporarily decline in human’s immune, especially cellular immunity. Lack of effective immune reactions can lead to secondary bacterial and multiple infections. We investigated measles-infected patients and evaluated susceptible factors for multiple drug-resistant bacteria infections. We also examined hospital infection prevention and control protocol in controlling measles outbreaks in our hospital.

Materials and methods
During 2013 to July 2015, 492 cases of patients with measles were detected in our hospital. We retrospectively reviewed and analyzed 51 measles-infected cases who had multiple drug-resistant bacteria infection data.

Results
We found that the main risk factors to be infected with multiple drug-resistant bacteria included: 1) age under 8 months, 2) abnormal cardiac functions, 3) having malnutrition and 4) having encephalitis.

Conclusions
The hospital should focus on patients under 8 months of age, with abnormal cardiac functions, having malnutrition or encephalitis to avoid multiple drug resistant bacteria infections and decrease mortality by strengthening treatment and implementation of infection prevention and control protocols.

E2: A local experience sharing: hand wash basin as a potential source of carbapenemase-producing Enterobacteriaceae transmission in hospital environments

Man Ying Kong, Christopher Koon Chi Lai, Suet Yi Lee, Ngai Chong Tsang

Background
The global spread of Carbapenemase-producing Enterobacteriaceae (CPE) is a major challenge for infection control practitioners.We adopted a proactive approach that all CPE carriers were isolated in a designated ward with strict contact precautions. Here, we investigated if CPE can survive terminal disinfection in hospital environment. Our study aimed to evaluate the extent of CPE contamination in patient care environment after terminal disinfection using microbiological sampling.

Materials and methods
Microbiological samples for CPE were taken from the general wards’ environment whenever a patient newly identified with CPE was removed for isolation. Environmental samplings were collected by trained personnel. High-touch and wet surfaces were sampled using sterile Polywipe sponge. ChromID CARBA agar was used for selective cultivation of CPE. Suspicious colonies grown after overnight incubation at 35 °C were further examined for carbapenemase production using CARBA-NP. We confirmed carbapenemase production using GeneXpert CARBA.

Results
Between 7 April 2014 and 4 October 2016, 468 environmental samples were collected from 23 wards. We found 1.92%tested positive for CPE that included7 hand-wash basins, one sink and one hospital curtain. These isolates were IMP-producing CPE. Six affected basins/sinks were cleared from CPE after cleaned with detergent followed by disinfection with 5.25% sodium hypochlorite solution (1,000 ppm) daily for one week. The CPE in the remaining two hand-wash basins survived for 21 days after daily decontamination and the basins need to be replaced.

Conclusions
Our results highlighted hand-wash basins may serve as a potential environmental reservoir for CPE. As standardized decontamination regimen for sinks was lacking, we recommended hand-wash basins should not be used for the disposal of body fluids.

E3: Effectiveness of decontamination of isolation wards using the spectra 1000 ultra-violet c light system

MM O’Donoghue, MV Boost, LKP Suen, GK Siu, KW Mui, CKC Lai, DNC Tsang

Background
Terminal cleaning of isolation rooms is an essential step in infection control. However, traditional cleaning and disinfection may be inadequately performed by time limitation. Ultra-violet (UV) devices are effective in environmental decontamination but their cost can be prohibitive. Recently, a more economical version of a UV-C sterilizing unit has become available but its effectiveness for environmental decontamination has not yet been independently evaluated. Our study aimed to evaluate the effectiveness of the Spectra 1000 UVC light system to reduce viability of healthcare-associated pathogens in a ward environment.

Materials and methods
Four organisms (Staphylococcus aureus, Enterococcus faecalis, Acinetobacter baumannii and Klebsiella pneumoniae) were coated onto designated areas of formica that were then attached to eight locations in the room. The room was irradiated for 15 minutes and the lamp was moved to a second position then treatment was repeated. Cultures were performed and resulting colonies were enumerated. Surviving numbers were compared with non-irradiated controls.

Results
All organisms were rendered non-viable in areas receiving direct irradiation or substantial reflected light. At two sites where heavily shaded (rear of bedside lockers and armchairs), a 2-log reduction in viability of E. faecalis was observed.

Conclusions
Spectra 1000 UVC light offered an effective adjunct to conventional terminal disinfection of isolation rooms. Although two irradiation periods using two positions of the lamp were needed, to ensure that shaded areas would receive adequate treatment, the total time for disinfection was only 30 minutes. As UV treatment does not produce residues, there is no down time after use.

E4: The current status of cross-infection risks in hotels

Yuka Sato, Mariko Tateishi, Mutsuko Mihashi

Background
In Japan, the Ministry of Health, Labour, and Welfare published the “Guidelines for the Prevention of New Strains of Influenza Infections in Employers and Employees [1]”. However, our survey, which investigated infection control for new strains of influenza in 2014, revealed that recognition of these guidelines was low, showing that infection prevention control had been insufficiently implemented in hotels. Our study aimed to identify the current status of cross-infection risks in hotels, and use the results to improvethe control of infectious diseases in such areas.

Materials and methods
The study ran from March 17-18, 2016. The study volunteers were members of the All Japan Ryokan Hotel Association. To assess environmental contamination levels in hotel settings, the ATP and AMP swab test kits (Kikkoman Lumitester PD-20) were used. Frequently touched surfaces were measured for contamination. Measurement sites included 30 that were measured intermittently, and 39 that were measured before and after cleaning.

Results
There were 5 intermittently measured monitoring sites that exceeded 5,000 RLU including the open/close buttons inside the kitchen elevator and first floor handrails. There were 5 monitoring sites measured before and after cleaning that exceeded 5,000 RLU even after cleaning, including the inner sides of restaurants’ sliding doors and the inner washroom door knobs of guest rooms.

Conclusions
ATP values of more than 5,000 RLU were detected at some monitoring sites, suggesting the need to reconsider methods and frequency of cleaning by taking risk of cross-infection into account.

References:
1. Ministry of Health, Labour, and Welfare websate. Guidelines for the Prevention of New Strains of Influenza Infections in Employers and Employees (update 2009 Feb 17); http://www.mhlw.go.jp/bunya/kenkou/kekkaku-kansenshou04/pdf/090217keikaku-08.pdf (cited 2014 Oct 25)

E5: Utilization of infection control risk assessment tool in improving the compliance to infection prevention and control during construction activities in the hospital

Jose Paulo Flor, Marko Bautista, V Jay De Roxas, Justine Vergara, Nicolo Andrei Añonuevo, Marion Kwek, Jose Acuin, Anna Josea Sanchez, Avel Bathan

Background
The purpose of this study was to test the effectively of the Infection Control Risk Assessment (ICRA) monitoring tool developed by the Infection Prevention and Control Unit (IPCU) of Asian Hospital and Medical Center with the aim to increase the compliance of construction workers to recommended infection prevention and control measures during construction, renovation and demolition in the hospital.

Materials and methods
Indicated in the ICRA monitoring tool were the details of the activity and the infection risk level (Class I,II,III and IV). The design used wasa quasi-experimental designwhich was conducted among all construction projects in the hospital within a 1-year period. The percent compliance was computed by number of compliant projects per month over total number of monthly projects which thenmultiplied by 100.

Results
There were a total of 151 construction projects monitored by direct observation which utilized the ICRA tool. Other interventions included orientation of construction workers to the tool, acknowledgment and accountability of recommended infection prevention and control measures by signing the tool and lastly, making use of the tool to provide feedback. Results show an improvement in the compliance to infection prevention and control interventions from average of 84% during pre-intervention to 91% post intervention.

Conclusions
Having an ICRA tool paved the way for construction workers to be pro-active and be involved in preventing infections brought by construction, renovation and demolition.

E6: Garnering staff towards a cleaner and safer environment: the national kidney foundation experience

Jamilah Binte Jantan, Chua Chor Guek, Eu Chiow Kian, Pampe Anak Pirido, Nur Fadilah Binte Mohd Aron, Leah May Estacio, Francis Alvarez Palana, Michelle Gracia, Nur Syafiqah Binte Shamsuddin, Kersten Timbad Castro, Madonna Baloria, Faezah Binte Adam

Background
In the dialysis centre, there is potential for cross transmission of infectious agents through contaminated devices, hands, equipment, supplies and environmental surface during haemodialysis (HD) treatment. To reduce the risk of acquiring infections, staff routinely clean and disinfect medical equipment and high-touch areas after each patient's HD treatment at the National Kidney Foundation (NKF). This study aim of the study is to assess environmental cleaning of high-touch areas and develop intervention program to achieve compliance ≥85%.

Materials and methods
This is a quantitative study involving 29 Infection Control Link Nurses (ICLNs) at the Community-based Dialysis Centres (CB-DCs), NKF from October 2015 to April 2016. In November 2015, ICLNs conducted an environmental cleaning assessment of high-touch areas using a checklist and Glo Germ Kits, to ascertain the efficacy of environmental cleaning at 29 CB-DCs. Pre-study data showed an overall average of 67% compliance. RCA revealed the absence of an audit tool for high-touch areas, a lack of training leading to knowledge deficit, poor cleaning techniques and staff incompetency. Interventions included a checklist (audit tool) for environmental cleaning assessment of high-touch areas, a "Train the Trainer" programme for the 29 ICLNs, an annual competency assessment and video tutorials on environmental hygiene to standardise practice.

Results
Following the interventions, environmental cleaning assessment of high-touch areas showed an overall average of 86% compliance, with 17 CB-DCs achieving ≥85% compliance in environmental cleaning of high-touch areas.

Conclusions
This study illustrated that the intervention programme increased staff awareness, thereby improving compliance. Besides promoting positive outcomes, it enhanced the internal monitoring system at NKF.

E7: Are surfaces of gym equipment a source of methicillin-resistant Staphylococcus aureus (MRSA) colonisation in the rehabilitation centre?

Zhang Wei, Poh Bee Fong, Marimuthu Kalisvar, Angela Chow, Brenda Ang

Background
In March 2016, a surge of 34 MRSA acquisitions (30 from screening and 4 from urine cultures) was noted in rehabilitation ward (REH-ward) at Tan Tock Seng Hospital, Singapore. Our objective was to investigate if fomite transmission could be a cause of these acquisitions. We conducted one-day surveillance screening of the gym equipment and REH-ward’s environment.

Materials and methods
Samples were collected by rolling swabs moistened with sterile saline five times on the surfaces of gym equipment before and after use. In the ward, selected patients’ beds and common items or equipment in shared area were also sampled. Samples were cultured for MRSA using selective chromogenic media.

Results
In the gym, all 156 samples collected from equipment pre-use were negative for MRSA. However, 7.3% (6/85) of the samples collected after use were MRSA positive. In the wards, all swabs (55) that were taken from the common shared area such as computers, case notes carts, were negative. Two out of 12 beds (16.7%) occupied by MRSA carriers and 3 out of 53 beds (5.7%) occupied by non-MRSA carriers were contaminated with MRSA (OR 3.33, 95%CI 0.24- 32.46, p = 0.23). Overall rates of MRSA-positive swabs were comparable between the wards and gym (2.5% vs. 2.2%, p = 0.82).

Conclusions
Gym equipment was not more likely than the ward environment to contribute to MRSA acquisition. The importance of environmental cleaning in all areas including rehabilitation facilities cannot be over-emphasized.

E8: Reforming program of environmental cleaning

I-Ju Chuang, Yi-ChunCho, Yu-Fen Chiu, Lung-Chih Chen, Yi-Chun Lin, Shao-Xing Dong, Yi-Chieh Lee, Hui-Chen Kuan, Hsin-Hua Lin, Chia-Chun Chi, Chin-Te Lu

Background
With the widespread use of antibiotics in the treatment of human bacterial infections, the multidrug-resistant microorganisms also appear to threaten human health. Environmental cleaning to avoid the spread of bacteria and healthcare-associated infection is an important part of healthcare infection control practice. Through this program, our hospital aimed to improve the environmental cleaning, reduce the bacterial antibiotics resistance, and further reduce the use of antibiotics.

Materials and methods
We reformed program of environmental cleaning and measured incidence of multidrug-resistant bacteria and consumption of designated antibiotics.

Results
Our results were shown below. The unqualified rate in environmental cleanliness of our cleaners was 39.1% before this program was implemented and 21.7% after this program that demonstrated 44.5% reduction. The numbers of healthcare-associated infections with multidrug-resistant bacteria was 30 before this program, and 8 after this program (73% reduction). The consumption of anti-methicillin-resistant Staphylococcus aureus was 142.0 defined daily dose (DDD) /1000 bed-days before this program, and 101.5 DDD /1000 bed-days after this program (28.5% reduction). The consumption of glycopeptides was 120.0 DDD /1000 bed-days before this program, and 83.2 DDD /1000 bed-days after this program (30.8% reduction). The consumption of carbapenems was 164.5 DDD /1000 bed-days before this program, and 98.1 DDD /1000 bed-days after this program (40.4% reduction).

Conclusions
According to our results, environmental cleaning may effectively reduce the number of healthcare-associated infections with multidrug-resistant bacteria and used of broad-spectrum antibiotics. If it can be promoted consistently, in accordance to the qualified data, the use of antibiotics could be reduced and the prevention of bacterial resistance occurred

E9: To investigate the expiry date of antimicrobial curtain

Fu-chieh Chang, Chang-pan Liu

Background
The invention related to an antibacterial treatment process of a curtain fabric material with functions of free washing and environmental protection. They were used for the antibacterial treatment of a non-woven fabric made from polypropylene fibers and as the curtain fabric material with functions of free washing and environmental protection. Before our hospital use this production, we aimed to investigate the expiry date of antimicrobial curtain to establish our protocol.

Materials and methods
We conducted this experiment from August to October 2016. In this study, we used three companies’ antimicrobial curtains. We used the C.difficile, MRSA and A. baumannii as study models. Then we putted the antimicrobial curtain on the agar then see the bacteria growth or not.

Results
According to our study, C. difficile, MRSA and A. baumannii were not detected in the antimicrobial curtains. After 11 weeks, there were no bacteria growths on the curtain.

Conclusions
The curtain fabric material produced by the invention has the advantages of good air permeability, easy maintenance of dry curtain fabric surfaces, dirt resistance, free washing, no toxicity and irritative peculiar smell, easy recycling, environmental protection, good antibacterial property and low antibacterial treatment cost.

E11: Evaluation of the appropriateness of the standard operating procedure and propose amendments to ensure of the cleaning/disinfection in Intensive Care Unit

Tang Ya-Fen1, Su Li-Hsiang, Liu Jien-Wei1

Background
Environmental contamination is the important source for bacterial spread causing hospital-acquired infections. Environmental cleaning with an established standard operation procedure (SOP) and cleaning staff’s strict adherence to the SOP are therefore extremely important. However, evaluation of the effects of environmental cleaning in general has not been fully reported in the literature. This study aim to elucidate the effects of environmental cleaning with the established SOP and by the well trained cleaners in Kaohsiung Chang Gung Memorial Hospital (KSCGMH). Environmental cleaning was based on the SOP which followed the principle of cleaning from higher locations to lower ones, and from the contaminate areas to the comparatively cleaner ones in rooms where patients were staying.

Materials and methods
Before and after daily environmental cleaning routine, environmental surfaces were swabbed for sampling specimens for bacterial culture and for bacterial count evaluation in case of culture positive.

Results
Data showed that before and after cleaning environmental, bacterial burdens in environmental surfaces of the bedroom were significantly reduced (p < 0.0001).

Conclusions
Indicating the environmental cleaning with the current cleaning SOP and by these well trained cleaners has been effective.

E12: Hospital-wide environmental cleaning monitoring program reduces healthcare-associated infections related to multidrug-resistant organism

Hsuehlan Chao, PinRu ChangChien, WeiFang Chen, ChungHsu Lai

Background
The evidence-based policies to clean hospital environment can reduce the colonization and infection of multidrug-resistant organisms (MDROs). The purpose of this study is to measure the effectiveness of environmental cleaning policies.

Materials and methods
(1) The effectiveness of policies was examined by adenosine triphosphate (ATP) and microbial cultures (MCs) before and after the implementation of policies at both the general wards (GWs) and the intensive care units(ICUs). (2)The study audited selected 20 points related to MDROs, including bed rails, bed button beds (the desktop corner), etc.(3)The standard values: ATP less than 250 RLU at ICU and less than 500 RLU at GW. Bacterial colonies count < 100 CFU.

Results
(1)20/49 ATPs (41%) had been detected over 500RUL before policies, but 28/67 (42%) after policies without statistical difference (p = 0.45) in GWs. However, in ICUs, before policies 40/81 ATPs (49%) over250 RLU and after policies 30/67 ATPs over 250 RLU, no statistical difference (p = 0.29). (2) 50% selected points were over 500RUL both before and after policies at GWs. Only 16.6% selected points were over 250RUL in ICUs. (3) MCs had statistically significant (p = 0.01) before and after policies at GWs, including Oxacillin-Resistant Staphylococcus aureus (ORSA), Enterococcus faecium (VRE), Acinetobacter baumannii, (XDR).But ICUs were not dirty over standard both before and after policies.

Conclusions
This survey helps us understand how much dirty and contamination in the environment. Especially, bed rails, button, isolation unit, car-related equipment, room telephone, curtains. Establishing good environmental policies are very important to prevent healthcare-associated infections. ICUs environment is cleaner than GWs in this study.

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