Alexandra Ward, MA

Investigators in Seoul, South Korea, successfully contained an outbreak of carbapenem-resistant 

 (CRAB) in a COVID-19 isolation ward by employing enhanced environmental cleaning and adding additional gowning and gloving protocol.

Clinicians caring for patients with COVID-19 are always concerned about the development of multidrug-resistant infections, which can complicate patient cases. CRAB, in particular, is a problematic nosocomial pathogen that is difficult to eradicate because of its ability to survive for long periods of time on dry surfaces and its resistance to common disinfectants.

, held October 19-23, 2022, in Washington, DC, investigators detailed the action taken after the index case of CRAB infection was detected in an 85-year-old female patient with COVID-19 who was referred to a tertiary South Korean hospital from a long-term care facility in October 2021.

A total of 23 patients with COVID-19 and CRAB were reported during the outbreak period. Fourteen (60.9%) were male and the mean patient age was 72.9 years (

 13.8). Of the initial specimens collected, CRAB was identified in the sputum of 21 patients (91.3%), in the blood of 6 patients (26.1%), in the urine of 1 patient (4.3%), and in the skin swab of 1 patient (4.3%). The average duration from admission to CRAB isolation was 13.3 days (

 11.0), and a majority (18, 78.3%) of patients were applying high-flow nasal cannula or ventilation. The most common underlying comorbidities at baseline included hypertension, diabetes mellitus, and cardiovascular disease (16/69.6%, 10/43.5%, and 8/34.8%, respectively).

Investigators determined via environmental culture that the CRAB outbreak occurred mainly around the index case, as the phenotypic antimicrobial resistance patterns of the isolates collected from patients and from the environment were identical.

“We applied the environmental cleaning using sodium hypochlorite (NaClO) 1000 ppm and phenolic compounds more than twice a day, enhanced hand hygiene, and additional gowning and gloving over personal protective equipment (PPE) mandatory for COVID-19 on 29th October,” investigators reported. “No additional CRAB cases occurred since 2nd November 2021 for 2 weeks.”

The team concluded that it is helpful to employ additional contact precautions and environmental cleaning in COVID-19 isolation wards alongside regular COVID-19 precautions, such as personal protective equipment, in order to prevent multidrug-resistant infections.

Articles

Using COVID-19 precautions, and enhanced contact precautions and environmental hygiene,  a COVID-19 isolation ward was able to contain an outbreak of CRAB.

Containing Outbreak of Carbapenem-resistant Acinetobacter baumannii in a COVID-19 Ward

Globally, environmental surfaces within patient rooms are a significant cause of 

health care-associated infections (HAIs). 

improved and expanded mitigation strategies

Because sporicidal disinfectants are necessary to control 

, innovative application methods such as electrostatic sprayers may increase disinfection effectiveness. The investigators of a recent study published in the 

, Sodium Dichloroisocyanurate (NaDCC), and Peracetic Acid (PAA/H2O2) with Hydrogen Peroxide for the Disinfection of Patient Room Surfaces,”

 used a standardized protocol to evaluate 3 sporicidal disinfectants, including electrolyzed water (EW), sodium dichloroisocyanurate (NaDCC; PURTABS, Earthsafe, Massachusetts), and peracetic acid/hydrogen peroxide (PAA/H2O2; Oxycide, Ecolab, Minnesota).

“In addition to developing environmental surveillance to assess disinfection of surfaces within patient care locations, new sporicidal chemical disinfectants, and application methods with minimal toxicity and surface damage profiles are needed to combat the rise of surface-persistent pathogens,” the investigators noted in the study. “EW, NaDCC, and PAA/H2O2 are less toxic and corrosive than bleach-based products, but efficacy data based on routine use in the health care setting is scarce.”

The investigators analyzed 774 samples. Overall, NaDCC-disinfected surfaces had a lower mean colony count (14 CFU) compared with PAA/H2O2 (18 CFU, 

 = .36) and EW (37 CFU, P < .001). PAA/H2O2 and EW had more samples with any growth (both 

 < .05) compared with NaDCC. NaDCC applied with wipes and an electrostatic sprayer had the lowest number of samples with no growth and < 2.5 CFU/CM2 (difference not statistically significant).

The study was conducted at 2 New York City hospitals with a combined 1082 beds over 18 months. The use of electrostatic sprayers was incorporated into EW and NaDCC. The investigators sampled five surfaces in randomly selected rooms for microbial colony counts after cleansing. Data analyses were performed using negative binomial logistic regression.

 spoke with Rich Prinz, global vice president of sales for EvaClean (manufacturer of the PURTABS), and Brian Spada, area vice president, Mid-Atlantic, to further understand the implications of the data.

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A recent study by NYU Langone investigators determined that disinfecting high-touch surfaces within patient rooms with NaDCC via wipes and electrostatic sprayers yielded lower mean bacteria colony counts. 


Selecting the Best Disinfectant/Application Method: Keeping C difficile and C auris at Bay

In order to address barriers to hand hygiene (HH) compliance among health care workers (HCWs), we must first understand the behavior on an individual level, particularly in the intensive care unit (ICU) setting.

A team of investigators at the University of Louisville set out to gather data on HH compliance and patient contact time among ICU HCWs using an electronic sensor-based HH measurement system called Sanibit by Microsensor Labs. The wearable wristband works with location sensors throughout the hospital to track HH and HCW behavior, and then pairs with an app that analyzes individual performance. The data were presented in a poster at the 

Association for Professionals in Infection Control and Epidemiology (APIC) 2022 Annual Conference

, held June 13-15, 2022, in Indianapolis, Indiana.

“The takeaway from this study is really there is significant individual variation by day of the week, by hour of the day,” Jiapeng Huang, MD, PhD, professor and vice chairman of the Department of Anesthesiology & Perioperative Medicine at the University of Louisville, co-founder of Microsensor Labs, and study presenter, told 

Data were collected from 15 HCWs (12 nurses, 2 patient care assistants, and 1 secretary) at a 10-bed surgical ICU and analyzed to track HH compliance by day of the week, hour of the day, dispenser location, and patient care duration. A total of 27,692 interactions were recorded over a 6-month period.

Notably, investigators found that HH was performed more regularly upon exit from the patient room compared with entrance (37.3% vs 26.1%; 

 < .001). HH compliance rates varied widely among individuals but stayed relatively stable when comparing day of the week and hour of the day, except for weekends when compliance dipped.

Overall, investigators note that their findings reinforce the need for continuous education and reminders that are specific to HCWs, time, and location.

“Technology is just a tool,” Huang said. “If you just buy the technology, your HH will not improve. You have to have the entire package…The more we study HH, the more complex we realize it is.”

The wearable wristband works with location sensors throughout the hospital to track HH and HCW behavior, and then pairs with an app that analyzes individual performance.

Digital Wristband Provides a Fuller Picture of Hand Hygiene Compliance in an Intensive Care Unit

Health care systems must get wound classification correct in order to paint an accurate picture of surgical site infection (SSI) rates, which, in turn, drive prevention efforts. However, some electronic medical records provide default wound classification that is not always accurate.

Infection preventionists can play a role in ensuring accurate wound classification in order to provide more precise SSI surveillance and reporting, according to a presentation at the 

, held June 13-15, 2022, in Indianapolis, Indiana.  

®, Emily Grohs, MPH, CIC, infection preventionist at Cincinnati Children's Hospital Medical Center, detailed her talk on a standardized approach to wound class and its impact on the surgical site infection rate. 

This transcript has been edited for clarity and length.

®: To start, can you talk about the importance of proper wound classification in general and what spurred you to pursue the research in this presentation?

Grohs: Every procedure should have a wound classification assigned to it that's usually assigned by the surgeon or the surgical team. For infection preventionists, we use that for surgical site infection (SSI) surveillance and for reporting. Depending on how you report your SSIs, you may have to report by wound class.

®: What is the current state of wound classification and what challenges exist?

Grohs: I can't speak for everybody, but for our institution…specifically, for wound class, our biggest challenges right now are getting the correct wound classification. We are trying to be with technology…we have an electronic medical record that will actually default a wound classification, so trying to be one step ahead. One less thing to think about while you're in the operating room. But we found that it's not always accurate and really also requires that human factor. That piece is kind of missing. Our surgical team really relies heavily on the default part, so when an IP is doing surveillance, we’ll usually go and find that the correction is not always there.

®: Can you walk us through the research you conducted?

Grohs: I started SSI surveillance for the institution about a year ago. We went through our whole process as I was learning this and found that there are gaps in our current process that can possibly affect the rate that we are believing is true. We did a retrospective review of all SSIs over the past 3 years and looked at the wound classes for both the default wound class, also [how] the infection preventionist was classifying the wounds and, from there, came up with 3 different SSI rates and just showing how, depending on where you pull your data from, it does have an effect on your SSI rate.

We found that the biggest takeaway is that, of all the SSIs we culled over that 3 years, about 42% of them required a wound class change by an infection preventionist. So, assuming that the IP is following your wound class policy, 42% of them were not correct, and then a little over half of the ones that we did change were changes that would have an effect on our SSI rate, which was kind of a shocking result.

®: Armed with these data, where do you go from here?

Grohs: Now that we have all that data, which is nice to have when you're presenting to perioperative leadership or other people who have a stake in the game and care about SSIs and want to do anything to target efforts to prevent SSIs…we have that data and we have presented it to perioperative leadership. They have a few different interventions that we're looking to try. Obviously, re-education is one of them, putting wound class back at the forefront of the education for new employees, recertification. We've also talked about possibly removing the default aspect of the wound class. That's a less popular option. We're trying to do a few different interventions before we actually go there, but those are the ones that we've started so far.

“Of all the SSIs we culled over that 3 years, about 42% of them required a wound class change by an infection preventionist,” Emily Grohs, MPH, CIC, tells ICT®.

How Wound Classification Impacts Surgical Site Infection Rate

Hospitals rely heavily on portable medical equipment, including workstations on wheels (WOWs). However, these machines are prone to contamination by health care worker (HCW) hands and could potentially serve as fomites in the transmission of health care–associated infections (HAIs).

In an effort to glean more knowledge into potential contamination associated with WOWs, a team of investigators at Central Texas Veterans Healthcare System conducted a longitudinal assessment of contamination patterns on the equipment. Findings were presented in a poster at the 

“Periodic disinfection of equipment is required in most hospitals, but multiple surfaces on an equipment may not be adequately disinfected all the time. In addition, the complexity of demands on staff may limit their ability to properly disinfect an equipment,” the research team reported. “The purpose of this study was to determine if current disinfection practices were effectively managing bioburden on WOWs on our hospital wards.”

Using press plates, investigators collected bioburden data from 10 WOWs on each of the 3 units in the hospital over a 4-week period, assigned at random. Samples were taken 4 consecutive days per week (Monday-Thursday) at 3 different time points (9AM, noon, and 3PM). Specific WOW areas sampled included the keyboard, mouse, arm, and tray. Investigators calculated aerobic bacterial colony counts after 24 hours of incubation and used Bayesian multilevel models to estimate the mean bioburden and compare it across locations sampled.

Technicians planned to collect a total of 480 samples, although 28 were lost because the portable medical equipment was in use at the time or unable to be found. After modeling, the estimated mean colony count and 95% UI for press plates takes from WOWs was 29.2 (range, 16.1–51.1) counts.

Estimated mean colony counts were much higher for the arm of the WOW (58.8 [range, 35.2–91.2]) compared with the keyboard (24.7 [range, 14.5–37.2]), the tray (17.0 [range, 10.0–26.4]), and the mouse (12.5 [range, 7.4–19.3]).

“The IRRs for keyboard compared to arm was 0.43 (0.32–0.55), for tray compared to arm was 0.29 (0.22–0.38), and for mouse compared to arm was 0.22 (0.16–0.29),” investigators reported.

The bioburden disparities among the various locations sampled could mean a number of things. It could mean HCWs are not practicing proper hand hygiene before using or moving WOWs. It could also reflect the number of touches, a discrepancy in cleaning methods, or differences in where individual users touch WOWs the most.

“It is also possible that the differences in bioburden levels among these locations is due to the sampling process rather than the result of the bioburden accumulation process, as the keyboard and mouse may be more difficult to sample with a press plate,” the research team concluded. “The correlation of bioburden to HAI transmission was not studied here so the significance of bioburden alone in the absence of HAI monitoring is uncertain.”

The bioburden disparities among the various locations sampled could mean HCWs are not practicing proper hand hygiene before using or moving WOWs. It could also reflect the number of touches or a discrepancy in cleaning methods. 

Workstations on Wheels: Contamination Patterns Show Arm Used for Moving Carries Highest Bioburden

Hand hygiene (HH) compliance experienced a bump during the COVID-19 pandemic when the practice came under the microscope, but health care worker (HCW) adherence remains low nationwide. To gain a more accurate understanding of why, a 3-hospital network in Illinois conducted a HCW survey and presented the results at the 

Infection prevention and quality investigators across the 3 health care facilities—Advocate Christ Medical Center in Chicago, Illinois; Advocate Trinity Hospital in Chicago; and Advocate Aurora Healthcare in Mokena, Illinois—developed a 14-item anonymous survey comprising Likert, Yes/No, and open-ended questions. The goal was to gain more insight into HCW’s current HH practices and perceived barriers to compliance in order to identify opportunities for improvement. The team set a goal outcome of 3 potential interventions that could be implemented across the network.

Led by John P. Delano, MPH, CIC, manager of infection prevention at Advocate Christ Medical Center in Chicago, Illinois, investigators distributed the survey via email beginning in July 2021, allotting 2 weeks for HCW completion. Some of the items on the survey included “clarity of HH education received, perceived HH effectiveness, willingness to provide and/or receive real-time feedback, assessment of potential perceived barriers, and evaluation of effectiveness of potential targeted interventions,” according to the poster.

The resulting data were analyzed and results were provided in a Microsoft Excel sheet in August 2021.

In all, 1001 HCWs completed the survey. HCWs acknowledged the benefits of proper HH, with 92% responding that HH is “very effective” at preventing patients and self from acquiring infections and 93% saying they would be receptive to someone asking them to perform HH if they were seen not doing so.

However, only 45% of HCW surveyed admitted that they would “always” remind a team member to perform HH if he or she forgot to do so.

When it comes to barriers, only 15% of HCWs surveyed said that availability of HH products (ie, dispensers are often empty) either always, most of the time, or some of the time contributed most to them not performing proper HH. More than 80% of those surveyed felt supplementing the network’s existing secret shopper HH auditing program with real time feedback and coaching would be somewhat or very effective at boosting HH compliance.

Armed with the survey data, investigators developed an action plan, presented it to leadership, implemented interventions, and then audited via a secret shopper program in December 2021.

During a 4th quarter audit conducted post-intervention, HH compliance scores increased for 2 out of the 3 hospitals in the network, with 1 hospital registering a > 20% improvement in HH compliance.

“Survey and preliminary HH audit results suggest that interventions aimed at improving the availability of [alcohol-based hand rub], encouraging peer-to-peer reminders, and supplementing existing auditing processes with real time feedback and coaching may have greater impact on HH compliance than education alone,” investigators concluded.

Health care worker hand hygiene compliance ticked up during COVID, but levels remain low nationwide. A 3-hospital network in Illinois wanted to know why.