A unified framework for developing effective hygiene procedures for hands, environmental surfaces and laundry in healthcare, domestic, food handling and other settings

Hygiene procedures for hands, surfaces and fabrics are central to preventing spread of infection in settings including healthcare, food production, catering, agriculture, public settings, and home and everyday life. They are used in situations including hand hygiene, clinical procedures, decontamination of environmental surfaces, respiratory hygiene, food handling, laundry hygiene, toilet hygiene and so on. Although the principles are common to all, approaches currently used in different settings are inconsistent. A concern is the use of inconsistent terminology which is misleading, especially to people we need to communicate with such as the public or cleaning professionals. This paper reviews the data on current approaches, alongside new insights to developing hygiene procedures. Using this data, we propose a more scientifically-grounded framework for developing procedures that maximize protection against infection, based on consistent principles and terminology, and applicable across all settings. A key feature is use of test models which assess the state of surfaces after treatment rather than product performance alone. This allows procedures that rely on removal of microbes to be compared with those employing chemical or thermal inactivation. This makes it possible to ensure that a consistent "safety target level" is achieved regardless of the type of procedure used, and allows us deliver maximum health benefit whilst ensuring prudent usage of antimicrobial agents, detergents, water and energy.

Rationaler Antibiotikaeinsatz Daten aus dem mre-netz regio rhein-ahr aus einer Umfrage von 2014 und Vergleich mit bundesweiten Daten von 2009

Einführung Die Bedeutung von multiresistenten gramnegativen Erregern als Ursache von lebensbedrohlichen Infektionen lässt dem Antibiotic Stewardship höchste Bedeutung zukommen.

Ziel Erkennen von Schwächen bei Antibiotikaverschreibungen in Krankenhäusern und Vergleich zwischen 2009 und 2014.

Methoden Ein Fragebogen wurde 2014 an alle 380 Ärzte von 7 Krankenhäusern, der Grund-, Regel- und Maximalversorgung verteilt. Erfasst wurden berufliche Entwicklung, Funktion, Kenntnisstand und Vorhandensein und Einsatz von Regeln zum Umgang mit Antibiotika. Die 119 beantworteten Fragebögen von 2014 wurden mit den 3613 aus 2009 verglichen.

Ergebnisse 31% der Fragebögen wurden zurückgeschickt, 53,8% von Assistenzärzten, die Hälfte ohne Facharztanerkennung. 32,8% wurden von Oberärzten, 12,6% von Chefärzten beantwortet. 22.6% waren Internisten, 18,4% Chirurgen, 10,9% Urologen und 9,2% Anaesthesisten. Mehrheitlich wurden Antibiotika täglich verschrieben, von Assistenzärzten zu 66%. 23% der Assistenzärzte gaben an, täglich andere Kollegen zu beraten und 61% mind. 1-mal in der Woche. Der häufigste Anlass hierfür ist die perioperative Antibiotikaprophylaxe (35), der Harnwegsinfekt (32) und die Pneumonie (29). Die Standarddauer der Gabe war 7 Tage bei Pneumonie, 5 Tage beim Harnwegsinfekt und 1 Tag bei der perioperativen Antibiotikaprophylaxe.In fast der Hälfte der Fälle wurde die perioperative Antibiotikaprophylaxe auf 3, 5, 7,8 und 10 Tage ausgedehnt. 93,3% der Ärzte berichteten Antibiotikaleitlinien des eigenen Hauses oder von Fachgesellschaften zu benutzen. Nur 59,3% wussten über die Resistenzen an ihrem Arbeitsplatz Bescheid. 52,1% verschreiben Breitspektrumantibiotika ohne Rücksprache mit dem Oberarzt oder Chefarzt. Im Vergleich zu 2009 sind Kenntnisstand über Antibiotikaresistenzen des Hauses, Benutzung von Leitlinien und Rücksprache mit Ober- bzw. Chefarzt jeweils um ca. 5% angestiegen.

Schlussfolgerung Trotz Verbesserung im Vergleich zu 2009 kannten 38,9% der Befragten die antibiotische Resistenzlage in ihrem Haus nicht und die Hälfte aller Chirurgen setzte die perioperative Prophylaxe länger als 24 Stunden ein. Da die Bereitschaft antibiotische Leitlinien zu benutzen mit 93,3% sehr hoch ist, sollten diese ausgeweitet und regelmäßig an die Resistenzlage angepasst werden. Ferner sollte die perioperative Antibiotikaprophylaxe länger als einen Tag wegen der zusätzlichen Nebenwirkungen ohne weiteren Benefit kritisch hinterfragt werden.

Antibiotic resistance: What is so special about multidrug-resistant Gram-negative bacteria?

In the past years infections caused by multidrug-resistant Gram-negative bacteria have dramatically increased in all parts of the world. This consensus paper is based on presentations, subsequent discussions and an appraisal of current literature by a panel of international experts invited by the Rudolf Schülke Stiftung, Hamburg. It deals with the epidemiology and the inherent properties of Gram-negative bacteria, elucidating the patterns of the spread of antibiotic resistance, highlighting reservoirs as well as transmission pathways and risk factors for infection, mortality, treatment and prevention options as well as the consequences of their prevalence in livestock. Following a global, One Health approach and based on the evaluation of the existing knowledge about these pathogens, this paper gives recommendations for prevention and infection control measures as well as proposals for various target groups to tackle the threats posed by Gram-negative bacteria and prevent the spread and emergence of new antibiotic resistances.

Intraneural injection of a test dose of local anesthetic in peripheral nerves - does it induce histological changes in nerve tissue?

BACKGROUND & OBJECTIVES

Most anesthesiologists use the injection of a test dose of local anesthetic in order to evaluate the final needle tip position. Thus, the intraneural injection of a full dose can be avoided. The aim of this study was to analyze whether an intraneural injection of a test dose of bupivacaine could trigger histological changes.

METHODS

Intraneural injections under direct vision were performed in 40 brachial plexus nerves in seven anesthetized pigs. Tibial nerves served as positive and negative controls. Two milliliter of bupivacaine 0.5% was injected in three nerves on the left brachial plexus. For control of local anesthetic's toxicity Ringer's solution was applied intraneurally on the right side. After maintaining 48 h of general anesthesia, the nerves were resected. The specimens were processed for histological examination and assessed for inflammation (hematoxylin and eosin stain, CD68-immunohistochemistry) and myelin damage (Kluver-Barrera stain). The degree of nerve injury was rated on a scale from 0 (no injury) to 4 (severe injury).

RESULTS

Statistical analysis showed no significant differences between the bupivacaine group [median (interquartile range) 1 (1-1.5)] and the Ringer's solution group [1 (0.5-2) P = 0.772]. Mild myelin alteration was found in 12.5% of all specimens following intraneural injection, irrespective of the applied substance.

CONCLUSIONS

"In our experimental study, intraneural injection of 2 ml of bupivacaine or Ringer's solution showed comparable mild inflammation. Nevertheless, inflammation can only be prevented by strictly avoiding nerve perforation followed by intraneural injection, as mechanical nerve perforation is a key factor for evolving inflammation.

Epidemiological investigation and case-control study: a Legionnaires' disease outbreak associated with cooling towers in Warstein, Germany, August-September 2013

Between 1 August and 6 September 2013, an outbreak of Legionnaires' disease (LD) with 159 suspected cases occurred in Warstein, North Rhine-Westphalia, Germany. The outbreak consisted of 78 laboratory-confirmed cases of LD, including one fatality, with a case fatality rate of 1%. Legionella pneumophila, serogroup 1, subtype Knoxville, sequence type 345, was identified as the epidemic strain. A case-control study was conducted to identify possible sources of infection. In univariable analysis, cases were almost five times more likely to smoke than controls (odds ratio (OR): 4.81; 95% confidence interval (CI): 2.33-9.93; p < 0.0001). Furthermore, cases were twice as likely to live within a 3 km distance from one identified infection source as controls (OR: 2.14; 95% CI: 1.09-4.20; p < 0.027). This is the largest outbreak of LD in Germany to date. Due to a series of uncommon events, this outbreak was most likely caused by multiple sources involving industrial cooling towers. Quick epidemiological assessment, source tracing and shutting down of potential sources as well as rapid laboratory testing and early treatment are necessary to reduce morbidity and mortality. Maintenance of cooling towers must be carried out according to specification to prevent similar LD outbreaks in the future.

Rapid genotyping of Legionella pneumophila serogroup 1 strains by a novel DNA microarray-based assay during the outbreak investigation in Warstein, Germany 2013

Between 1 August and 6 September 2013, an outbreak of Legionnaires' disease (LD) with 78 cases confirmed by positive urinary antigen tests occurred in Warstein, North Rhine-Westphalia, Germany. Legionella (L.) pneumophila, serogroup (Sg) 1, monoclonal antibody (mAb) subgroup Knoxville, sequence type (ST) 345, was identified as the epidemic strain. This strain was isolated from seven patients. To detect the source of the infection, epidemiological typing of clinical and environmental strains was performed in two consecutive steps. First, strains were typed by monoclonal antibodies. Indistinguishable strains were further subtyped by sequence-based typing (SBT) which is the internationally recognized standard method for epidemiological genotyping of L. pneumophila. In an early stage of the outbreak investigation, many environmental isolates were found to belong to the mAb subgroup Knoxville, but to two different STs, namely to ST 345, the epidemic strain, and to ST 600. A majority of environmental isolates belonged to ST 600 whereas the epidemic ST 345 strain was less common in environmental samples. To rapidly distinguish both Knoxville strains, we applied a novel typing method based on DNA-hybridization on glass chips. The new assay can easily and rapidly discriminate L. pneumophila Sg 1 strains. Thus, we were able to quickly identify the sources harboring the epidemic strain, i.e., two cooling towers of different companies, the waste water treatment plants (WWTP) of the city and one company as well as water samples of the river Wester and its branches.

Strategies for the reduction of Legionella in biological treatment systems

A community-wide outbreak of Legionnaire's disease occurred in Warstein, Germany, in August 2013. The epidemic strain, Legionella pneumophila Serogruppe 1, was isolated from an industrial wastewater stream entering the municipal wastewater treatment plant (WWTP) in Wartein, the WWTP itself, the river Wäster and air/water samples from an industrial cooling system 3 km downstream of the WWTP. The present study investigated the effect of physical-chemical disinfection methods on the reduction of the concentration of Legionella in the biological treatment and in the treated effluent entering the river Wäster. Additionally, to gain insight into the factors that promote the growth of Legionella in biological systems, growth experiments were made with different substrates and temperatures. The dosage rates of silver micro-particles, hydrogen peroxide, chlorine dioxide and ozone and pH stress to the activated sludge were not able to decrease the number of culturable Legionella spp. in the effluent. Nevertheless, the UV treatment of secondary treated effluent reduced Legionella spp. on average by 1.6-3.4 log units. Laboratory-scale experiments and full-scale measurements suggested that the aerobic treatment of warm wastewater (30-35 °C) rich in organic nitrogen (protein) is a possible source of Legionella infection.

In vitro study on the disinfectability of two split-septum needle-free connection devices using different disinfection procedures

This in vitro study investigated the external disinfection of two needle-free connection devices (NFC) using Octeniderm^® (spraying and wiping technique) vs. Descoderm^® pads (wiping technique). The split-septum membrane of the NFC was contaminated with >10⁵ CFU K. pneumoniae or S. epidermidis. The efficacy of the disinfection at 30 sec. exposure time was controlled by taking a swab sample and by flushing the NFC with sterile 0.9% sodium chloride solution. Disinfection with octenidine dihydrochloride 0.1 g, 1-Propanol 30.0 g, and 2-Propanol 45.0 g in 100 g solution was highly effective (CFU reduction ≥4 log) against both microorganisms, whereas the use of 63.1 g 2-Propanol in 100 ml solution led to residual contamination with S. epidermidis. Our investigation underlines that (i) in clinical practice disinfection of NFCs before use is mandatory, and that (ii) details of disinfection technique are of utmost importance regarding their efficacy. Our investigation revealed no significant differences between both split-septum NFC types. Clinical studies are needed to confirm a possible superiority of disinfectants with long-lasting residual antimicrobial activity.

Analysis of Transmission of MRSA and ESBL-E among Pigs and Farm Personnel

Livestock-associated bacteria with resistance to two or more antibiotic drug classes have heightened our awareness for the consequences of antibiotic consumption and spread of resistant bacterial strains in the veterinary field. In this study we assessed the prevalence of concomitant colonization with livestock-associated methicillin-resistant Staphylococcus aureus (LA-MRSA) and enterobacteriaceae expressing extended-spectrum betalactamases (ESBL-E) in farms at the German-Dutch border region. Nasal colonization of pigs with MRSA (113/547 (20.7%)) was less frequent than rectal colonization with ESBL-E (163/540 (30.2%)). On the individual farm level MRSA correlated with ESBL-E recovery. The data further provide information on prevalence at different stages of pig production, including abattoirs, as well as in air samples and humans living and working on the farms. Notably, MRSA was detected in stable air samples of 34 out of 35 pig farms, highlighting air as an important MRSA transmission reservoir. The majority of MRSA isolates, including those from humans, displayed tetracycline resistance and spa types t011 and t034 characteristic for LA-MRSA, demonstrating transmission from pigs to humans. ESBL-E positive air samples were detected on 6 out of 35 farms but no pig-to-human transmission was found. Detection of ESBL-E, e.g. mostly Escherichia coli with CTX-M-type ESBL, was limited to these six farms. Molecular typing revealed transmission of ESBL-E within the pig compartments; however, related strains were also found on unrelated farms. Although our data suggest that acquisition of MRSA and ESBL-E might occur among pigs in the abattoirs, MRSA and ESBL-E were not detected on the carcasses. Altogether, our data define stable air (MRSA), pig compartments (ESBL-E) and abattoir waiting areas (MRSA and ESBL-E) as major hot spots for transmission of MRSA and/or ESBL-E along the pig production chain.

[Hospital disinfection challenges due to multiresistant pathogens in surgery]

The number of antibiotic-resistant pathogens is increasing continuously while the development of new, effective antibiotics cannot be expected in the near future. Postoperative infections represent most of the nosocomial infections by now. Based on this, hygienic strategies regain importance, since a sustainable control of nosocomial infections will not succeed without the implementation of such strategies. In this article, the most important preventive strategies for prevention of infections with MRSA and 3- and 4-fold resistant gram-negative bacteria on the basis of current recommendations of the Commission for Hospital Hygiene and Infection Prevention (KRINKO) are presented.

Krankenhaushygienische Herausforderungen durch multiresistente Erreger in der Chirurgie

Die Anzahl antibiotikaresistenter Erreger steigt kontinuierlich an, ohne dass in den nächsten Jahren mit der Entwicklung neuer, wirksamer Antibiotika zu rechnen sein wird. Postoperative Infektionen stellen mittlerweile mit die häufigsten nosokomialen Infektionen dar. Vor diesem Hintergrund erlangen Hygienestrategien wieder eine neue Bedeutung, ohne deren Umsetzung eine nachhaltige Kontrolle nosokomialer Infektionen nicht gelingen wird. In diesem Artikel werden die wichtigsten Präventionsstrategien zur Prävention einer Infektion mit MRSA sowie 3- und 4-fach resistenten gramnegativen Erregern auf der Grundlage der aktuellen Empfehlungen der Kommission für Krankenhaushygiene und Infektionsprävention (KRINKO) gegeben.

Auf die Präventionsstrategien zu den ebenso als nosokomiale Infektionserreger relevanten Vancomycin-resistenten Enterokokken (VRE) und Clostridium difficile soll in einem zukünftigen Beitrag eingegangen werden, da hierzu die Empfehlungen der KRINKO derzeit noch in Bearbeitung sind.

Evaluation of an MPN test for the rapid enumeration of Pseudomonas aeruginosa in hospital waters

In this study, the performance of a new most probable number (MPN) test (Pseudalert(®)/Quanti-Tray(®)) for the enumeration of Pseudomonas aeruginosa from hospital waters was compared with both international and national membrane filtration-based culture methods for P. aeruginosa: ISO 16266:2006 and UK The Microbiology of Drinking Water - Part 8 (MoDW Part 8), which both use Pseudomonas CN agar. The comparison based on the calculation of mean relative differences between the two methods was conducted according to ISO 17994:2014. Using both routine hospital water samples (80 from six laboratories) and artificially contaminated samples (192 from five laboratories), paired counts from each sample and the enumeration method were analysed. For routine samples, there were insufficient data for a conclusive assessment, but the data do indicate at least equivalent performance of Pseudalert(®)/Quanti-Tray(®). For the artificially contaminated samples, the data revealed higher counts of P. aeruginosa being recorded by Pseudalert(®)/Quanti-Tray(®). The Pseudalert(®)/Quanti-Tray(®) method does not require confirmation testing for atypical strains of P. aeruginosa, saving up to 6 days of additional analysis, and has the added advantage of providing confirmed counts within 24-28 hours incubation compared to 40-48 hours or longer for the ISO 16266 and MoDW Part 8 methods.

Focused intraoperative transthoracic echocardiography by anesthesiologists: a feasibility study

BACKGROUND

Focused transthoracic echocardiography (TTE) is frequently used perioperatively for hemodynamic monitoring and diagnosis of cardiovascular instability, but less commonly intraoperatively.

METHODS

To evaluate the feasibility of intraoperative TTE, we enrolled 222 anesthetised patients from August to November 2012 into a prospective observational study. 162 patients underwent TTE examination according to the Focused Assessed Transthoracic Echocardiography (FATE) protocol after positioning and draping for surgery. Sixty additional hemodynamically unstable subjects were examined during anesthesia and surgery. The imaging quality of four FATE views was rated on a scale from 1 (impossible) to 5 (perfect). TTE was assessed as applicable, if at least two of the four basic FATE views were graded 4 or 5, or three views were assessed as grade 3.

RESULTS

Imaging quality was unacceptable in 20 patients, resulting in a feasibility rate of 91% (97.5%-CI 0.86-1, P=0.01). TTE was feasible in hemodynamically unstable subjects (91.7%; 97.5%-CI 0.82-1.0), in orthopedic and trauma patients (>95% respectively, [97.5%-CI 0.83-1]) and in abdominal surgery (78%).

CONCLUSION

TTE can be applied in the operating theatre during surgery, although its use during abdominal surgery is somewhat limited.