Throughout the evolution of antimicrobial stewardship (AMS) programs in healthcare, the role of the infection preventionist (IP) has not been clearly defined. AMS programs are an effort to coordinate the activities of pharmacy, providers, nursing, infection prevention, and administrators to align policy and practice around antimicrobial prescribing in ways that are optimal for patient care and appropriate for maintaining proper use to help alleviate the burden of antimicrobial resistance and other potential negative outcomes that can result in patient harm. 

Those harms have long been noted. The continued misuse of antimicrobials is driving up the resistance of numerous types of pathogens and prodding the US Centers for Disease control and Prevention (CDC), the World Health Organization (WHO), and other national and international health authorities to focus more on AMS programs.

The IP has always been called on as a partner and collaborator of AMS programs, as the goals of AMS dovetail with many of the goals of IP programs. However, depending on many factors, how involved the IP is in the program varies from facility to facility.

In some facilities, the IP is seen as the champion for the AMS program and would be instrumental in getting the program started and building support to move forward with the effort. Commonly the IP is the chair or co-chair of the committee. Pharmacy representatives are also usually a co-chair, as well as perhaps infectious disease physicians. 

The specialty of an infectious disease pharmacist is not available in many settings, therefore the leadership of the committee often has a learning curve about the principles and concepts of AMS and how that could be implemented in their organization. IP is a useful partner in the establishment of new committees and initiatives, as much of the work of an IP involves gathering stakeholders, researching best practices, and working with a multidisciplinary team to reach mutual objectives. Also, the IP often has relationships with the various groups involved in AMS committees, so they are a good resource to bring those parties together. However, IPs are not the expert in prescribing and administering antimicrobials, so the knowledge of providers and pharmacists is essential in taking the core concepts and then translating them into operational models for the organization.

Numerous professional societies have seen the need for the promotion of AMS activities and have developed toolkits, training courses, online resources, and professional education that is available for practitioners who are new to the concepts or need some help in developing AMS programs in their facilities. The Joint Commission and other accrediting bodies have included AMS programs in requirements for survey. The CDC included AMS programs in its 2019 Conditions of Participation. Based on data from the CDC, these efforts have increased the percentage of hospitals with active AMS programs from 41% in 2018 to 85% in 2018.

One role that IPs bring to AMS is to provide outcomes data related to multidrug-resistant organisms and negative patient outcomes, such as healthcare-onset 

occurrences. Along with providing data, IPs often perform case review of healthcare facility infections and potential impacts that antimicrobial use may have had in those cases. When doing case reviews, it is important that the IP alone is not looking at the prescribing, as a joint review with pharmacy or infectious disease physicians can provide a deeper insight into the selection based on patient diagnosis. 

As AMS programs become more established, the role of the IP can move away from the leader of the group and take on other duties in order to innovate the program and bring other related concepts to the team. Staff and patient education are a huge part of what an IP does on a daily basis. Often frontline staff are not aware of the AMS activities in their facility and how they can contribute to the program. 

This is an opportunity for the IP to develop educational programs and share with staff about AMS and how it impacts their work, and vice versa. Nurses in particular can also be a vital part of AMS work, as they are interacting with the patients, assessing signs and symptoms, and communicating with providers routinely. By providing some insight into the concepts of AMS at the facility, the nurses can act as an advocate from the patients with providers and also educate patients on why antibiotics may not be necessary or why a certain medication is not appropriate.

IPs can also help educate patients. Often we hear of patients going to the physician and expecting to walk out of the office with something tangible, so a prescription for an antimicrobial may be given to ensure patient satisfaction. IPs can partner with providers in the inpatient and outpatient arenas to teach patients about when an antimicrobial is needed, and when other alternatives should be used. Scripting can be developed so that a consistent message is sent to the patient from the moment they walk in the door, get checked in, and get called back for the initial assessment to when the provider sees them. 

Diagnostic stewardship is becoming the new hot topic, which is a perfect companion to AMS activities. IPs have been looking at diagnostic stewardship for many years, focusing on educating about the signs and symptoms associated with urinary tract infections or 

, and providing guidance on appropriate testing. 

These activities can be overseen by the AMS committee and policy and procedures can be established, utilizing electronic medical records and other platforms, to set up criteria that make clinical sense when ordering tests. For instance, pan culturing is still commonly seen in healthcare systems and should be considered a possible inappropriate use of resources that can potentially lead to inaccurate interpretation of test results if the full clinical picture of the patient is not considered.

Though CMS and some medical associations want outpatient, non-acute healthcare facilities to have robust AMS programs, there still exists a gap in the implementation of AMS in settings such as primary care offices, long-term care facilities, acute rehabs, behavioral health settings, dental clinics, and pediatric offices. IPs in these settings may have to be the champion to initiate AMS programs. There are resources for outpatient settings available, however the oversight that is seen in hospitals is not the same and can be a barrier to support, as there are many other competing priorities. This is where the IP can leverage expertise in developing that burning platform, call to action, and determine and engage those stakeholders within their organization who can help drive change.

AMS and IP programs are strong partners in the work to decrease multidrug-resistance and promote positive patient outcomes. IPs can bring their perspective and strengths to the AMS program and offer ways to bring the work to the bedside and engage the partnerships that already exist to make AMS programs successful.

Rebecca Leach, RN, BSN, MPH, CIC, has been an infection preventionist since 2010, with a background in nursing and epidemiology. Leach, a regular contributor to Infection Control Today, currently works at a healthcare system in Phoenix that includes 5 hospitals and more than 100 outpatient treatment centers.

1.    Centers for Disease Control & Prevention. Antibiotic resistance & patient safety portal. CDC wesite. 

Articles

Infectoin preventionists's can bring their perspective and strengths to the antimicrobial stewardship (AMS) program and offer ways to bring the work to the bedside and engage the partnerships that already exist to make AMS programs successful.

Go Team! IPs and Antimicrobial Stewardship Programs Take On Superbugs 

Hand hygiene is one of the most basic and important infection prevention efforts in the fight against infectious diseases, yet it is also often the most neglected. Although more recent headlines on the novel coronavirus have focused more on masks and personal protective equipment (PPE), it is imperative to remember and reiterate the role of hand hygiene and the complexities of recent research on the topic. The World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) each consider hand hygiene to be the best way to prevent the spread of infectious diseases. Hand hygiene is considered the foundation of infection prevention. 

For many infection preventionists (IPs), hand hygiene in healthcare facilities is often subpar. National compliance rates tend to fall well under 50% and even with interventions, sustainable improvement is a unicorn IPs are always in search of.

Hand hygiene compliance is tricky though, as healthcare workers are constantly going in and out of rooms, interacting with patients, and performing other activities that would necessitate hand hygiene protocols per the guidance of the World Health Organization. The development of alcohol-based hand sanitizer has relieved some of this stress by making the process faster and more efficient. Unfortunately, this is not without some exclusions, though.

One of the most important lessons IPs can teach staff is when to use hand sanitizer and when to wash with soap and water. The US Centers for Disease Control and Prevention (CDC) notes that “alcohol-based hand sanitizers can quickly reduce the number of microbes on hands in some situations, but sanitizers do 

Current education holds that hand sanitizer is a great option, but washing with soap and water should be standard protocol when hands are visibly soiled/dirty or when caring for a patient with norovirus or 

For years, the ability to rapidly clean one’s hands with sanitizer alone was truly an invention that healthcare workers and IPs alike were excited about. But some cracks in the foundation of the beloved hand sanitizer began to show in late 2019. 

The limitations of hand sanitizers have been known from the beginning, but it was a new study that raised red flags about its utilization for respiratory viruses, like influenza.

Flu season has always been a time for reiterating “don’t forget to clean your hands!” so of course the finding that hand sanitizer might be less effect than handwashing against flu was deeply concerning. 

The recently published study examined the infection control capabilities of alcohol-based hand sanitizers during flu season, focusing specifically on the influenza A virus.

What the research team found was fascinating, but also concerning: The hand sanitizer’s ability to inactivate the virus changed when the mucus (sputum) of an influenza A-infected person was present, meaning that the efficacy of the alcohol-based hand sanitizer decreased in the presence of sputum. The influenza A virus in mucus remained active despite 120 seconds of hand sanitizer use. When mucus is present, the virus tended to require higher sanitizer concentrations and longer periods of time to be inactivated. 

These findings are significant for a number of reasons. First, it shows the limitations of hand sanitizer in an application environment previously thought to be effective. Second, it underscores how mucus and sputum can pose challenges for disinfectants, reinforcing that handwashing is often the more effective option. Handwashing with soap and water is the only effective way to remove bioburden and the “gunk” that poses challenges for truly clean hands. The physical process of scrubbing is what aids in cleaning one’s hands. Although it’s easy to focus on hand hygiene as a broad topic during respiratory virus season, this study is a good reminder that staff should be encouraged to physically wash their hands more and not rely so heavily on hand sanitizers. 

Following this concerning finding, on January 17, 2020, the US Food and Drug Administration (FDA) released a warning letter to GOJO Industries regarding its Purell products.

More precisely, the Purell Healthcare Advanced Hand Sanitizer product line. A warning letter from the Division of Pharmaceutical Quality Operations is never a good thing, but especially not during an outbreak of a novel coronavirus or a severe flu season. The letter called out the company for marketing claims that the product is capable of killing a wide range of microbes. Some of these claims include efficacy against viruses like Ebola virus, norovirus, and influenza, etc. The response from the FDA was:

“These statements, made in the context of the Frequently Asked Questions section, clearly indicate your suggestion that PURELL® Healthcare Advanced Hand Sanitizers are intended for reducing or preventing disease from the Ebola virus, norovirus, and influenza. As such, the statements are evidence of your products’ intended uses. However, FDA is currently not aware of any adequate and well-controlled studies demonstrating that killing or decreasing the number of bacteria or viruses on the skin by a certain magnitude produces a corresponding clinical reduction in infection or disease caused by such bacteria or virus.”

Moreover, the FDA called out GOJO for the claims, which would designate the hand sanitizer in the “drug” category per FDA regulations. The letter heavily emphasized that the claims made by GOJO regarding the product were not supported by adequate or well-controlled clinical trials and published literature, noting that “You should take prompt action to correct the violations cited in this letter. Failure to promptly correct these violations may result in legal action without further notice, including, without limitation, seizure and injunction.”

Samantha Williams, GOJO’s senior director of corporate communications, told 

in Februarythat the company took “immediate action” upon receiving the FDA letter. She added that the letter was not related to the safety or quality of Purell products, or of the company’s manufacturing processes.

Overall, the efficacy of hand sanitizers has taken a hit over the past 6 months. Although this is not to say these products are not effective against microbes, it’s a stark reminder of the need for a wholistic approach to hand hygiene. It’s important to educate and reiterate with healthcare workers and all hospital employees-as well as visitors and patients-that hand sanitizers can be effective tools in specific situations, while handwashing with soap and water can be used in all situations. 

Although infection prevention efforts often focus on when hand sanitizers 

be used, perhaps it is time to shift gears and explore when they 

be used. An effective strategy for this might be incorporating a more positive approach while reminding people that sanitizers, like any technology or medical intervention, are not be-all, end-all products. Overall, the role of hand sanitizer has always been one where explanation was required and with the recent literature and concerns from the FDA, perhaps it is time infection prevention efforts adjust how hand hygiene is communicated. Reiterating the importance of effective handwashing for all who enter a healthcare facility is critical to ensure patients safety. We all have a role in infection prevention and as research changes what can and can’t be used, it’s important that such efforts also evolve and adjust to stay relevant and effective. 

Saskia v. Popescu, PhD, MPH, MA, CIC, is a hospital epidemiologist and infection preventionist. During her work as an infection preventionist, she performed surveillance for infectious diseases, preparedness, and Ebola-response practices. She holds a doctorate in biodefense from George Mason University where her research focuses on the role of infection prevention in facilitating global health security efforts. She is certified in infection control and has worked in both pediatric and adult acute care facilities. 

New Dirt on Hand Sanitizers Muddies Claims About Effectiveness

Think of it, says Vineet Chopra MD, MSc, as being a sort of 

Seal of Approval for infection prevention products. Chopra is chief of the division of hospital medicine at VA Ann Arbor Health System. He’s also the corresponding author of an article that lays out a new system that infection preventionists (IPs), hospital administrators, and others on the frontlines of infection control can use to evaluate infection control devices. 

“That’s precisely what we were thinking about when we were creating the tool,” Chopra tells 

analogy. “If you’re a busy IP in a hospital and are thinking about investing in new technology, how could you tell if it was worth it? This approach also focuses on what data sources/evidence matters when you need to make the choice and sends a signal to industry as to what sources of truth we will be considering when reviewing products.”

Chopra and co-investigators published the article outlining how the tool-a 1-page framework form-works last November in the 

. Healthcare officials can access the framework in the article or on the US Centers for Disease Control and Prevention’s (CDC) website. The tool was created by the Products and Practices Workgroup of the CDC’s Healthcare Infection Control Practices Advisory Committee (HICPAC).

HICPAC was charged with developing a process that would educate healthcare officials at the CDC, hospitals, and other settings about product choices. That covers a lot of ground, from ultraviolet light cleaning enhancers used by the environmental services (EVS) staff to the silver alginate dressings for the prevention of central line-associated bloodstream infections (CLABSIs) that Chopra’s article uses as one of its examples. 

“It was purposefully defined to be as broad as possible,” Chopra says. “So, our definition includes the gamut of devices from dressings, coatings, disinfectant devices, et cetera.”

The tool involves use of what the article calls nodes, lettered A to O. The Products and Practices Workgroup, which met quarterly from July 2017 to November 2018, included representatives of the US Food and Drug Administration (FDA), the CDC, and members of medical professional societies. 

The workgroup wanted product assessments to “span labeling, marketing, and regulatory data; evidence supporting use of a product; a summary of benefits and harms; consideration of effectiveness and generalizability; and resource implications,” the article states. “The workflow provides, for the first time, a rigorous, standardized method for reviewing products for infection prevention. It also broadens the type of information guideline writers will be able to review when considering products within infection prevention recommendations.” 

Chopra says that, “Our initial indicators are that it has many page views. As to whether it will catch on? Time will tell.”

Linda Spaulding RN, CIC, BC, CHEC, CHOP, an infection prevention consultant and a member of  ICT®'s Editorial Advisory Board, thinks that the tool will provide hospital administrators and IPs with some direction. “There have been so many products coming on the market that it is more important than ever for hospitals and IPs to do complete evaluations,” says Spaulding, who served as a liaison member of the HICPAC working group.

Connie Steed, MSN, RN, CIC, FAPIC, the president of the Association for Professionals in Infection Control and Epidemiology (APIC), says that the tool was designed for HICPAC and CDC and won’t necessarily affect the day-to-day for IPs or hospital administrators; they may use it way down the line, though.

“I think it’s a very comprehensive tool,” says Steed. “There’s so much innovation going on that when they’re reviewing guidelines, they need to look at what’s out there.” 

She adds that the framework’s rigorousness makes it time-consuming. “It was not intended for infection preventionists to use but I could see where it would be helpful to infection preventionists,” says Steed, adding that it’s not really ready for hospitals to use either-yet.

“In the future, you may see this used by a healthcare organization,” says Steed. 

On the other hand, manufacturers of infection control devices might find the tool very useful. “It gives you really a roadmap to what HICPAC and CDC is looking at in a product that they would recommend and a guideline for you to reduce infection risk. It’s very detailed. I’ve learned a lot by looking at the tool and understanding things that we need to be looking for as we assess products.” 

Chopra said Steed is correct in saying that the tool right now is designed to determine how HICPAC will make product recommendations. He adds, however, that Steed is also correct that hospital administrators and IPs will hopefully find the tool useful someday.

“We didn’t design this to be a research tool,” Chopra says. “Rather, it was designed to be a pragmatic approach to looking at the evidence and data. One that we hope will diffuse beyond CDC and HICPAC.”

As the article states, the manufacture and sale of such devices represents a $27 billion industry, with an annual growth rate of 4.9%. In the beginning and throughout most of its history, the CDC focused on healthcare delivery practices in infection prevention and not so much on the products used in that effort, confining its focus in that arena to “general categories,” as the article puts it. 

that “manufacturers and industry often will focus on specific outcomes. Evidence and peer-review may or may not focus on these. And FDA labels may or may not support the use of a product for that specific indication. This tool bridges the gap.”

HICPAC found instances where an FDA-approved device was used for something other than what it was meant for “when we did our review of the silver alginate and mupirocin products, for example,” Chopra says. “This may not all be negative-but the gaps are important to know.” 

HICPAC did 3 test runs on products that might be used on neonatal intensive care units (NICUs). They included, as mentioned, silver alginate dressings for the prevention of CLABSIs. 

“The tool was extremely useful when assessing the closed medication delivery system for the NICU CLABSI guideline because it led to the discovery that the product was not FDA-approved but rather a homemade, institution-specific device,” the article states. “The algorithm did identify clinically relevant human outcomes and the possibility of increased workload for nurses using the equipment. Evidence on generalizability, effect, and superiority of this product was not available, and the quality of the evidence in the guideline-review process was low. Therefore, the balance of benefits and harms assessed was unclear, and data summated from the tool did not support a recommendation that the product be used in neonates to reduce CLABSI.” 

that he can see several ways in which the tool can be used. “First, when choosing product A vs. product B for a specific need, this tool can help examine the data for both in a systematic way,” he says. “Second, the tool can be a great way for IPs to look for evidence for existing products to determine whether or not there is support for continued use. Third, the ability to think about resource implications to maintain a product is a new and important dimension that IPs and clinicians can use when looking at products and making decisions.”

The tool may also help avoid situations of false advertising with infection prevention products such as hand sanitizers. For instance, in January the FDA fired off a warning letter to GOJO Industries, the makers of Purell hand sanitizer products, saying that some of the claims made about those products on social media platforms were misleading. Specifically, the agency took umbrage with Purell’s claims that its products can reduce or prevent infection from Ebola, methicillin-resistant 

(MRSA), vancomycin-resistant Enterococcus (VRE), norovirus, influenza, and 

“Failure to promptly correct these violations may result in legal action without further notice, including, without limitation, seizure and injunction,” the letter stated. 

in Februarythat the company took “immediate action” upon receiving the FDA letter, adding that “it is our responsibility to ensure that we comply with all requirements of FDA regulations and federal law, and we take that responsibility very seriously.”

She also said that the letter was not related to the safety or quality of Purell products, or of the company’s manufacturing processes.

When asked how the HICPAC algorithm might have helped to prevent this situation, Chopra said “hindsight is 20/20.”

“The first few nodes of our algorithm that examine what the listed FDA indications for the product are would have caught this issue as it is currently written,” he told 

. “Of course, this all assumes that the nodes are followed and the directions are acted on by those using the tool.” 

Spaulding points to what Chopra describes as the “high degree of variation in the process through which hospitals make decisions about devices and products. Our hope is that this will streamline that approach-provide guidance where none truly exists.”

The tool uses nodes, lettered A to O, that assess products in a way that spans labeling, marketing, and regulatory data, says the CDC. It provides a rigorous standardized method for review.

CDC Devises Method for Reviewing Onslaught of New Infection Control Devices

Neonatal intensive care units (NICUs) can be breeding grounds for infection, but they also offer opportunities to provide better care through infection prevention. They do this, in part, by relying on infection preventionists (IPs) to perform one of the more delicate maneuvers in healthcare: Trying to educate laypeople about infection prevention.

It’s one thing to monitor and police fellow healthcare workers on the need to take extra precautions to prevent NICU infections. It’s quite another to try and stop family members from visiting these most vulnerable of patients. Parents or other relatives visiting in these units often hold the babies, as it is an important part of their care, but this can put the child into direct contact with infectious droplets or dirty hands. 

That being said, any person going in and out of a NICU poses a challenge for infection prevention efforts. This can put the IP in a tough position. Although hand hygiene, isolation precautions, and staying home while sick are all practices emphasized among healthcare workers, family and visitors don’t often get that message. Educating anyone coming into the NICU about the vulnerability of the patients and their role in infection prevention efforts is vital. 

Having conversations, empathy, and providing visitors/parents with the resources to avoid sharing germs goes a long way. Personal hand-gel containers, face masks, and requiring hand hygiene upon entrance can be helpful. Overall, there might be pushback and although you can’t prevent parents from visiting their children, working with them to understand the risks if they’re sick and giving them the tools to be a part of the care process through infection prevention can help empower them and reduce risk for the neonate.

Engaging family members and visitors in infection prevention efforts can help make them feel part of the care process while keeping the patient safe. However, that often requires 1 on 1 conversations and making accommodations.

 These are hospital units with extremely vulnerable patients, but they also provide a place for IPs to shine in their abilities to adapt and enhance measures without impacting patient care and family experiences. 

Created in the 1950s, the use of NICUs has resulted in a neonatal mortality rate decline from 18.73 per 1000 live births in 1955 to 4.04 per 1000 live births in 2002.

 The use of these units has also been increasing. Overall NICU admission rates have grown from 64 per 1000 live births in January 2007 to 77.9 per 1000 live births in December 2012.

  Investigators analyzing 18 million live births in the US during this time period found the increase across all birth weight categories, noting that in 2012 there were 43 NICU admissions per 1000 normal birth weight infants, while the admission rate for very low birth weight infants was 844.1 per 1000 live births.

The March of Dimes reports that in 2018, 10% of all US live births were preterm.

Congenital malformations and low birth weight tend to account for the largest portion of infant mortality in the United States. Interestingly, neonatal mortality is higher in the US than in comparable countries like Canada or Switzerland.

Since many newborns in the NICU are premature, their immune systems are not fully developed, which makes them susceptible to infections, especially opportunistic ones. Moreover, NICU patients are typically admitted for longer periods of time and often require invasive medical devices and/or procedures from central lines to ventilators and even Foley catheters, which increase the risk of healthcare-associated infections (HAI) and require the most diligent of infection prevention efforts. Infections in NICUs typically stem from methicillin-resistant 

(MRSA), and other bacterial pathogens. Prematurity inherently puts these patients at more of a risk as their natural defense systems-immune system and even skin-are not fully developed and more likely to have weaknesses.

The design of most NICUs is particularly unique and can create hurdles for infection prevention. NICUs are one of the few healthcare environments that allow for an open configuration, versus single-family room. The pinwheel configuration is unique in that it can include multiple neonates in several pods within a larger room. Although this setup may be helpful for nursing workflow, it also means that there is often more shared space and family/visitors are more likely to come into contact with surfaces/objects that are shared across babies. Studies have shown that those single-family rooms, despite being more costly, are more conducive to family-centered care and enhanced medical progress through reduced nosocomial sepsis and mortality.

Since neonates frequently require less space during the care process, this design not only makes patient care easier, but also utilizes less space. Ultimately, a single-family room is not only preferable, but helps reduce the risk that a sick visitor or healthcare worker would expose multiple babies.

There have been several NICU-centric outbreaks over the years that have offered hard lessons One 1997 outbreak of drug-resistant 

that occurred in a NICU resulted in extensive screening and changes in care.

Ultimately, screening efforts identified ready-to-use “disinfected” thermometers as the probable cause of the outbreak, likely due to rushed disinfection practices that led to such contamination. In fact, investigators determined that, despite banning the use of these thermometers, newly admitted neonates in the NICU became colonized and the unit ultimately had to be temporarily closed. Extensive screening efforts were implemented that encompassed all thermometers and rectal temperature probes. 

The research team there noted that “observation of disinfection procedures and a laboratory investigation revealed that ‘rushed’ disinfection with alcohol 80% led to a 1 in 10 chance of thermometers still being contaminated. Furthermore, alcoholic hand rub used for convenience disinfection failed to disinfect thermometers in 40% and 20% of the cases when done in a ‘rushed’ or ‘careful’ fashion, respectively.” Once adequate disinfection was enforced, the outbreak subsided and several months went by without additional cases. This is a prime example of not only the susceptibility of this patient population, but also how failures in environmental disinfection can be devastating to the entire unit. 

Although all patients require vigilant infection prevention measures and the goal should always be zero infections, the stakes are sometimes higher in the NICU, as infections there have higher potential for death. 

Saskia v. Popescu, PhD, MPH, MA, CIC, is a hospital epidemiologist and infection preventionist. During her work as an infection preventionist, she performed surveillance for infectious diseases, preparedness, and Ebola-response practices. She holds a doctorate in biodefense from George Mason University where her research focuses on the role of infection prevention in facilitating global health security efforts. She is certified in infection control and has worked in both pediatric and adult acute care facilities. 

1.Harrison W, Goodman D. Epidemiologic trends in neonatal intensive care, 2007-2012. JAMA Pediatrics. 2015 doi:10.1001/jamapediatrics.2015.1305.
	March of Dimes. 2020. United States Preterm Data. Accessed on January 28, 2020 from https://www.marchofdimes.org/peristats/ViewSummary.aspx?reg=99&stop=60

2. MCG. Neonatal Care and the Neonatal Intensive Care Unit: Challenges & Opportunities, MCG. 2018. Accessed on February 1, 2020 from https://www.ahip.org/wp-content/uploads/2018/11/MCG-White-Paper-Neonatal-Care-and-the-NICU-AHIP.pdf 

3. Domanico R, Davis DK, Coleman F, Davis BO. Documenting the NICU design dilemma: comparative patient progress in open-ward and single family room units. J Perinatol. 2011;31(4):281–288. doi:10.1038/jp.2010.120

4. Gastmeier P, Loui A, Stamm-Balderjahn S, Hansen S, Zuschneid I, Sohr D, et al. Outbreaks in neonatal intensive care units-They are not like others.
	Am J Infect Control. 2007;35(3):172-176, ISSN 0196-6553, https://doi.org/10.1016/j.ajic.2006.07.007.

5. Van den Berg RW, Claahsen HL, Niessen M, Muytjens HL, Liem K, Voss A. Enterobacter cloacae outbreak in the NICU related to disinfected thermometers. J Hosp Infect. 2000;45(1):29-34.

Although all patients require vigilant infection prevention measures and the goal should always be zero infections, the stakes are sometimes higher in the NICU, as infections there have higher potential for death.

NICUs Offer Infection Preventionists Opportunity to Show Their Worth 

Ultraviolet (UV) light can destroy pathogenic bacteria, including 

spores, but measuring the effectiveness of UV can be tricky, as investigators with Penn State Health, Milton S. Hershey Medical Center, found out. Their recent study in the 

describes the impact of portable pulsed-xenon UV disinfecting devices in 6 units of their hospital that had registered high 

rates were measured over a 9-month period before and a 9-month period after the devices were installed, with no difference in 

“Appropriate terminal cleaning evaluated by fluorescent marking environmental auditing did not significantly change over phase 1 and 2 study periods with an average of 87% of 6510 tested high-touch surfaces demonstrating adequate removal of fluorescent marker,” the study states. “Use of UV devices during the 9-month phase 2 study period in 2017 averaged 93.6% of 8298 targeted terminal discharges without notable differences in use between units.” 

infection (HA-CDI) per 1000 patient-days for the units during phase 1 was 1.57 of 1000 patient-days compared with 1.61 of 1000 patient-days during the phase 2 study for the same hospital units. 

Fibi Attia, MD, MPH, CIC, the study’s corresponding author and a member of 

 that although the findings didn’t necessarily surprise her, they did cause her to re-examine how best to use UV disinfection. 

“Although we were optimistic that UV disinfecting devices would reduce the burden of pathogens in the environment, we always try to evaluate our techniques and processes,” Attia says. “When we didn’t see any impact on our infection data, we studied it in more depth. We also know that there are many factors that contribute to 

infection rates. Even if microbe burden is decreased on surfaces that can be treated with UV, this in itself may not be sufficient to cut down 

Phase 1 of the study (when portable pulsed-xenon UV disinfecting devices were not used) occurred from January 2016 through September 2016. The devices were installed from October 2016 to December 2016, with full implementation by January 2017, which was when the 9-month phase 2 period of the study started. “Compliance reports for UV device utilization were generated automatically each time the device was used,” the study states. 

Terminal cleaning focuses on infection spread and can vary from hospital to hospital, but often involves cleaning walls and floors, and removing all detachable objects and disinfecting them before they are returned to the room. It is usually conducted by environmental services (EVS). 

The hospital rooms in the study were cleaned with a sporicidal disinfectant cleaning product: sodium hypochlorite in 2016, acid/hydrogen peroxide-based sporicidal in 2017. Randomly selected rooms were then subjected to fluorescent tagging to see how well they’d been cleaned. 

The diagnosis of HA-CDI was based on molecular detection of toxin-producing 

on a unformed stool specimen collected on or after the third calendar day of admission to a room. 

“Directly following room cleaning, UV disinfection devices are placed in the room to deliver UV in 2 or 3 positions, with a 5-minute run time per position,” the study states. “A room with a bathroom has 3 UV device positions per room (on either side of the bed and in the bathroom). If the room does not have a bathroom, 2 positions are used (on either side of the bed).” 

Attia says that “even if microbe burden is decreased on surfaces that can be treated with UV, this in itself may not be sufficient to cut down 

infection rates. The control of HA-CDI likely requires a multifaceted approach which includes not only maximal decontamination of the environment, but optimization of diverse factors from disinfection of medical equipment to antimicrobial stewardship.” 

The study also notes that it’s unclear how some of the mitigating circumstances for the pulsed-xenon UV disinfection in the final stage of terminal room cleaning may have affected HA-CDI rates. “The control of HA-CDI likely requires optimization of a multifaceted approach, including: excellent hand hygiene compliance, early identification of those with CDI and possibly also those with 

colonization, optimal environmental cleaning, dedicated medical equipment, excellent antimicrobial stewardship, and other measures that may enhance maximal decontamination of the environment,” the study states. “It is possible that one or more of these factors, if suboptimal, negated any positive.” 

Attia reiterates that “it is known that UV disinfection can destroy microbes, including 

spores. However, we have alluded to the many other factors that increase risk of 

. At this point it is difficult to ascertain how much each risk factor contributes to overall risk of 

including the benefit of UV disinfection after manual cleaning at the time patients are discharged.” 

Attia F, Whitener C, Mincemoyer S, Houck J, Julian K. The effect of pulsed xenon ultraviolet light disinfection on healthcare-associated Clostridioides difficile rates in a tertiary care hospital. Am J Infect Control. 2020;Jan 22. pii: S0196-6553(19)31083-1. doi: 10.1016/j.ajic.2019.12.019.

Xenon lamps produce pulsed flashes of germicidal UV light at wavelengths from 200-315 nm, killing microbes on environmental surfaces.

C. diff Contamination Not Affected by Ultraviolet Disinfection Devices 

Over the last decade, the world has experienced many outbreaks, pandemics and epidemics, from severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) to H1N1 influenza and now COVID-19. Since the symptoms of coronaviruses are similar to that of influenza, it is important to identify outbreaks early, contain them, and prevent person-to-person spread until identification of the cause of the outbreak can be determined. 

Coronaviruses can be found in many animal species including snakes, pangolins, camels, cattle, cats, and bats. It is uncommon for an animal coronavirus to infect people and then keep spreading person-to-person. But over the past decade, we have seen just that: 3 coronaviruses infecting humans and causing ongoing person-to-person transmission. 

In February 2003, there was an epidemic of SARS first reported in Asia. SARS, or SARS-associated coronavirus (SARS-CoV), spread to countries in North America, South America, Europe, and Asia before it was contained. An estimated 192 people were infected/ detected with SARS-CoV in the United States. Since 2004, no further episodes of SARS-CoV infection have been reported any place in the world. 

Next came the coronavirus called Middle East respiratory syndrome (MERS). First reported in Saudi Arabia in 2012, MERS has spread to several countries, including the United States. The largest MERS outbreak took place in South Korea in 2015. 

In May 2014, 2 of 1300 patients tested were diagnosed with MERS-CoV infection in the United States. These 2 people were identified as imported cases from Saudi Arabia. One case was in Indiana and the other was found in Florida. Both infections were thought to have arisen from healthcare workers from Saudi Arabia. Both patients made a full recovery. The US Centers for Disease Control and Prevention (CDC) completed an investigation of household members and the healthcare workers who cared for the 2 MERS cases. They all tested negative for the virus. 

Common human coronaviruses (types NL63, OC43, and HKU1) usually cause respiratory tract illnesses, such as the common cold. At some point in our lives, most of the population will become infected with a human coronavirus. 

Despite advances in medicine, global travel has complicated the ability to control the spread of infectious diseases. Both the 2003 SARS epidemic and the 2009 H1N1 pandemic were spread via air travel. Because of this, all healthcare providers must be aware of and alert to possible emerging diseases and understand how to identify, report, investigate, and contain any outbreak until the cause of the infection can be determined. But what is necessary to control any outbreak situation, whether it is a multidrug-resistant organism, influenza, or a novel virus like COVID-19? 

®, Bill Jarvis, MD, president of the consulting company Jason and Jarvis Associates, shared information about the CDC’s role in outbreak investigations. Whether an outbreak is suspected within or outside of the United States, the CDC can provide the following assistance, if invited: 

·      Trained Epidemic Intelligence Service (EIS) officers can travel onsite to assist with the investigation (in collaboration with local infection control personnel). 

·       Diagnostic specimen or samples of the suspect pathogen can be sent to the CDC’s laboratories for identification, serologic, or genetic testing. In the case of COVID-19, samples sent to the CDC would be processed in appropriate containment areas in the Division of Virology or Special Pathogens/Pathology Laboratories. Once new pathogens, such as COVID-19, are identified, gene sequencing and rapid diagnostic testing can be performed and sent to state and local health departments or even to ministries of health throughout the world. Depending upon the pathogen, the specimen/organism would be directed to the appropriate laboratory (ie, bacterial, fun- gal, viral, protozoan, etc.). A wide variety of specialized laboratories are available. 

·       Once the pathogen is identified, the CDC can then develop both rapid diagnostic tests (gene probes, serologic tests, etc.) and can provide such rapid or other diagnostic test kits both nationally and internationally to assist in the diagnosis, prevention, and control of the pathogen/ outbreak. 

·       In addition, either EIS officers or other members of the Division of Quarantine or taskforce personnel can be assigned to critical areas to assist in the control of the outbreak. With COVID-19, this has been seen by assigning CDC and state health department personnel to logistically important airports to assist in screening passengers for COVID-19 and assisting in the isolation of infected or potentially infected people. 

It is important to understand that the CDC is a non-regulatory US agency (aside from the National Institute for Occupation Safety and Health-NIOSH). Thus, whether the outbreak is located within or outside the United States, the CDC must be invited to assist by the local/state/national government and/ or healthcare facility. The World Health Organization (WHO) also must be invited. 

Possible outbreak situations are usually identified by an astute clinician, infection preventionist, or a clinical laboratory worker. First, a previously unrecognized (COVID-19) or unusual pathogen (MERS), or a pathogen with an unusual antimicrobial susceptibility pattern (vancomycin-resistant 

), or an unusual number of cases of a disease (cluster of plague) are noticed. For example, on a Monday morning, it is reported that 4 patients on 1 unit have developed cold symptoms. By Tuesday morning, the number of individuals sick with cold symptoms numbers 6. The continued increase in patients with the same symptoms should be investigated to determine whether there is a respiratory tract infection (RTI) of some type spreading through the facility. Since many coronavirus infections have the same signs and symptoms, it is important to contain the RTIs until the etiology/pathogen identification can be made. 

It will have to be determined whether it is the common cold, influenza, or possibly COVID-19. It is the responsibility of every medical professional to remain vigilant for early signs of a cluster or outbreak and to report possible outbreaks caused by new or novel pathogens or unusual multidrug-resistant organisms to the appropriate authorities (in many, if not most, states, legislation requires reporting of outbreaks to county and state health departments). For very unusual or novel outbreaks, both the countries’ ministries of health and the WHO and CDC should be notified as promptly as possible. Initial prevention and control (containment) can prevent spread within and outside the country of origin and potentially prevent a larger outbreak or pandemic. 

It is important to track all information using a tracking sheet. A tracking sheet can be adjusted depending on the symptoms identified in each outbreak situation. A well-developed tracking sheet is necessary to analyze all the data that is collected during an outbreak situation. Depending on the situation, the tracking sheet may be small such as for an influenza outbreak or more extensive to track things such as all the rooms a patient had been transferred to or what roommates they may have had, and possibility of exposure. 

Components of a simple tracking sheet include: 

Flu vaccination given y/n (if it’s flu season) 

Symptoms (ie, cold, sore throat, malaise, chills, muscle aches, 

Date hospitalized (if from a nursing home, etc.) 

Developing a tracking sheet makes it easier to systematically collect data, add new data, and analyze the existing data. Data can then be reviewed from any data point. 

1.    Early identification of a suspected outbreak.

3.    Define a case and an outbreak and pre-outbreak period.

4.    Communicate to all healthcare professionals that need to know.

5.    Identify all individuals who meet the case definition (patients and staff).

6.    Determine if the number of “cases” exceeds the background rate (ie, it is an outbreak).

7.    If reportable to local and state agencies, report those concerns. Local and state agencies can aid with case identification, development of investigative approach, prevention and control measures, and assist with specimens. 

8.    Appropriately isolate all individuals who meet the case definition. 

9.    Collect appropriate clinical specimens and save all outbreak-specific isolates from potential “cases.”

10.  Confirm a diagnosis (rule out a pseudo-outbreak).

11.  Be sure proper precautions are in place to contain the outbreak once a diagnosis is confirmed. You may decide to implement proper precaution prior to the diagnosis depending on the situation.

12.  Continue to monitor and control the outbreak in order to prevent future spread.

13.  Develop a line listing of “cases.”

14.  Compare exposures of “cases” to better understand the route of transmission and potential risk factors.

15.  Consider conducting additional epidemiologic studies (ie, case-control or cohort studies).

16.  Consider performing genetic studies of the pathogen (especially if previously unrecognized or unusual).

17.  Institute additional control measures, if needed.

18.  Evaluate the efficacy of the control measures.

19.  When control measures have terminated transmission, declare the outbreak is over.

20.  Communicate to all individuals and agencies involved in the investigation that the outbreak is over.

21.  Prepare your final outbreak investigation report.

22.  Provide the opportunity for a debrief to identify strengths and weaknesses in the investigation. Information should be obtained from all effected staff.

23.  Develop opportunities for improvement and action plans to avoid another outbreak.

Linda Spaulding, RN, CIC, BC, CHEC, CHOP, is an infection prevention consultant and founder of InCo and Associates International, Inc. 

Just How to Investigate an Outbreak: Evolution of the Interrogative Process From SARS to COVID-19

Every week brings something new with the novel coronavirus first identified in Wuhan, China. Reporting on case counts seems futile as these numbers are changing daily. The World Health Organization (WHO) has 

 for the disease though, COVID-19. “COVI” referring to coronavirus and “D” for disease, meaning that this is the name of the disease caused by the virus that will likely be called SARS-CoV-2. Similar to the naming aspects of HIV/AIDs, the COVID-19 refers to the illness and disease caused by the infectious agent, 2019-CoV (until it is officially given the taxonomy of SARS-CoV-2). 

While this will likely require communication with frontline healthcare workers to avoid confusion, hopefully this is a sign of more research and efforts to clarify things related to the virus and disease. This will be especially critical as personal protective equipment (PPE) shortages continue and infection preventionists will likely need to give guidance on the extended use and re-use of N95 masks. These are important topics to consider though, and now is the time for hospitals to engage in strategies or at least plan to potentially 

As of Feb. 11, 2020, the CDC has not changed its guidelines on criteria to evaluate people who may have been infected by 2019-nCoV. If cases continue to spread outside of China though, this might change, or ultimately travel-related screening will cease to be effective. As our current guidance for screening is heavily reliant on travel to the affected area or exposure to a known/suspected case, widespread transmission beyond China will weaken such criteria. 

There are two critical pieces of research that were released within the last week. The first was a study 

 the persistence of coronaviruses on inanimate objects and inactivation processes. While the authors evaluated research related to all coronaviruses that infect humans, they did find that across 22 studies, the virus can persist on inanimate objects (metal, glass, or plastic) for up to 9 days. Coronaviruses are enveloped viruses, meaning that they are easier to inactivate with disinfectants and that the use of EPA-registered hospital disinfectants is effective. The authors note that coronaviruses can be “efficiently inactivated by surface disinfection procedures with 62-71% ethanol, 0.5% hydrogen peroxide or 0.1% sodium hypochlorite within 1 minute. Other biocidal agents such as 0.05-0.2% benzalkonium chloride or 0.02% chlorhexidine digluconate are less effective.”

The second relevant piece of research that was recently published is a 

 in which the authors evaluated the clinical characteristics of 138 hospitalized patients with 2019-nCoV in Wuhan, China. Evaluation of these patients found two concerning pieces of information-26% required admission to an intensive care unit (ICU) and 41% of the 138 patients are believed to have acquired the disease through hospital transmission. 

These findings are concerning for a number of reasons. Firstly, patients in ICUs tend to require longer lengths of stay, which means more use of healthcare workers (infection preventionists among them) and other resources, and increases the patient’s risk for healthcare-associated infections (HAIs), but also the chance that 2019-nCoV could be transmitted. Secondly, the volume of HAIs is deeply worrisome as it shows, like SARS and MERS, hospitals easily act as amplifiers of these diseases during outbreaks. This further reinforces the need to continuously work with staff to rapidly identify, isolate, and inform, when potential patients are triaged. More importantly though, it emphasizes the need to focus on infection prevention efforts and how we can better avoid such transmission through the foundational efforts we teach on frequently. 

It's been given an official name, COVID-19, and will likely become known as SARS-CoV-2, when all is said and done. 