Risk of organism acquisition from prior room occupants: a systematic review and meta-analysis

Healthcare as a driver, reservoir and amplifier of antimicrobial resistance: opportunities for interventions

Antimicrobial resistance (AMR) is a global health challenge that threatens humans, animals and the environment. Evidence is emerging for a role of healthcare infrastructure, environments and patient pathways in promoting and maintaining AMR via direct and indirect mechanisms. Advances in vaccination and monoclonal antibody therapies together with integrated surveillance, rapid diagnostics, targeted antimicrobial therapy and infection control measures offer opportunities to address healthcare-associated AMR risks more effectively. Additionally, innovations in artificial intelligence, data linkage and intelligent systems can be used to better predict and reduce AMR and improve healthcare resilience. In this Review, we examine the mechanisms by which healthcare functions as a driver, reservoir and amplifier of AMR, contextualized within a One Health framework. We also explore the opportunities and innovative solutions that can be used to combat AMR throughout the patient journey. We provide a perspective on the current evidence for the effectiveness of interventions designed to mitigate healthcare-associated AMR and promote healthcare resilience within high-income and resource-limited settings, as well as the challenges associated with their implementation.

Indication-based and patient-based hand hygiene performance among nurses working at a university hospital

The traditional method of monitoring hand hygiene (HH) based on specific indications does not ensure that HH is performed for all required indications during patient care. This study aimed to compare HH performance rates (HHPRs) based on specific indications versus overall patient care among nurses at a university hospital. The study retrospectively analyzed HH monitoring data for 1398 indications from 543 patients and 190 nurses. Observations were conducted continuously, tracking a single healthcare worker from before patient contact until the end of the contact within a 30-min period. The indication-based HHPR was found to be 89.1%, while the patient-based HHPR was 78.1%. In the context of patient-based HHPR, the lowest rates were observed among nurses in the emergency room (48.3%) and those with less than 1 year of work experience (66.7%). Moreover, the largest discrepancy between indication-based and patient-based HHPR was noted among emergency room nurses with less than 1 year of experience. This significant difference underscores the need for patient-based HH monitoring, particularly for nurses in emergency settings and those with limited experience.

[Multi-resistant pathogens - are they also resistant to disinfectants?]

Epidemiological studies show that the care of patients in rooms with a previous stay by a person with evidence of multi-resistant pathogens (MRP) is associated with an increased risk of these pathogens occurring. The question therefore regularly arises as to whether MRP also exhibit resistance to the disinfectants used. To date, there are no standardised definitions for "resistance" to disinfectants. However, disinfectants authorised on the market are also effective against multi-resistant pathogens and the failure of efficient disinfection is mainly caused by application errors (insufficient cleaning, incomplete wetting, incorrect application concentration or exposure time etc.). The effectiveness of disinfectants depends on a variety of environmental factors (especially accompanying contamination). A reduced sensitivity to disinfectants can occur in individual isolates due to selection under sub-inhibitory concentrations of disinfectants. Resistance mechanisms to antibiotics do not mediate cross-resistance to disinfectants, but a change in the permeability of bacterial cells can influence sensitivity to disinfectants and antibiotics. In general, the success of routine disinfection can be improved by suitable process controls and contribute to reducing the transmission of MRP.

Visualizing and diagnosing spillover within randomized concurrent controlled trials through the application of diagnostic test assessment methods

BACKGROUND

Spillover of effect, whether positive or negative, from intervention to control group patients invalidates the Stable Unit Treatment Variable Assumption (SUTVA). SUTVA is critical to valid causal inference from randomized concurrent controlled trials (RCCT). Spillover of infection prevention is an important population level effect mediating herd immunity. This herd effect, being additional to any individual level effect, is subsumed within the overall effect size (ES) estimate derived by contrast-based techniques from RCCT's. This herd effect would manifest only as increased dispersion among the control group infection incidence rates above background.

METHODS AND RESULTS

The objective here is to explore aspects of spillover and how this might be visualized and diagnosed. I use, for illustration, data from 190 RCCT's abstracted in 13 Cochrane reviews of various antimicrobial versus non-antimicrobial based interventions to prevent pneumonia in ICU patients. Spillover has long been postulated in this context. Arm-based techniques enable three approaches to identify increased dispersion, not available from contrast-based techniques, which enable the diagnosis of spillover within antimicrobial versus non-antimicrobial based infection prevention RCCT's. These three approaches are benchmarking the pneumonia incidence rates versus a clinically relevant range, comparing the dispersion in pneumonia incidence among the control versus the intervention groups and thirdly, visualizing the incidence dispersion within summary receiver operator characteristic (SROC) plots. By these criteria there is harmful spillover effects to concurrent control group patients.

CONCLUSIONS

Arm-based versus contrast-based techniques lead to contrary inferences from the aggregated RCCT's of antimicrobial based interventions despite similar summary ES estimates. Moreover, the inferred relationship between underlying control group risk and ES is 'flipped'.

Physicochemical methods for disinfection of contaminated surfaces - a way to control infectious diseases

This paper represents the reviews of recent advancements in different physicochemical methods for disinfecting contaminated surfaces, which are considered to be responsible for transmitting different bacterial, viral, and fungal infectious diseases. Surface disinfection can be achieved by applying chemicals, UV-based processes, ionization radiation (gamma-ray, X-ray and electron beam), application of self-disinfecting surfaces, no-touch room disinfection methods, and robotic disinfection methods for built-in settings. Application of different chemicals, such as alcohols, hydrogen peroxide, peracetic acid, quaternary ammonium salts, phenol, and iodine solution, are common and economical. However, the process is time-consuming and less efficient. The use of UVC light (wavelength: 200-280 nm, generated by low vapor mercury lamps or pulse xenon light) has gained much attention for disinfecting fomites worldwide. In recent times, the combination of UV and H2O2, based on the principle of the advanced oxidation process, has been applied for disinfecting inanimate surfaces. The process is very efficient and faster than chemical and UV processes. Heavy metals like copper, silver, zinc, and other metals can inactivate microbes and are used for surface modification to produce self-disinfecting surfaces and used in healthcare facilities. In combination with UVB (280-315 nm) and UVA (315-400 nm), titanium oxide has been utilized for disinfecting contaminated surfaces. Ionization radiation, one of the advanced methods, can be used in disinfecting medical devices and drugs. Post-COVID-19 pandemic, the no-touch and robotic disinfection methods utilizing chemicals or UVC lights have received much importance in built-in settings. Among these methods, surface disinfection by applying chemicals by fogging/vaporization and UV radiation methods has been widely reported in the literature compared to other methods.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40201-024-00893-2.

The role of the hospital bed in hospital-onset Clostridioides difficile: A retrospective study with mediation analysis

OBJECTIVE

To determine whether residing in a hospital bed that previously held an occupant with Clostridioides difficile increases the risk of hospital-onset C. difficile infection (HO-CDI).

METHODS

In this retrospective cohort study, we used a real-time location system to track the movement of hospital beds in 2 academic hospitals from April 2018 to August 2019. We abstracted patient demographics, clinical characteristics, and C. difficile polymerase chain reaction (PCR) results from the medical record. We defined patients as being exposed to a potentially "contaminated" bed or room if, within the preceding 7 days from their HO-CDI diagnosis, they resided in a bed or room respectively, that held an occupant with C. difficile in the previous 90 days. We used multivariable logistic regression to determine whether residing in a contaminated bed was associated with HO-CDI after controlling for time at risk and requiring intensive care. We assessed mediation and interaction from a contaminated hospital room.

RESULTS

Of 25,032 hospital encounters with 18,860 unique patients, we identified 237 cases of HO-CDI. Exposure to a contaminated bed was associated with HO-CDI in unadjusted analyses (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.4-2.31) and adjusted analyses (OR, 1.5; 95% CI, 1.2-2.0). Most of this effect was due to both mediation from and interaction with a contaminated hospital room.

CONCLUSIONS

Residing in a hospital bed or room that previously had a patient with C. difficile increases the risk of HO-CDI. Increased attention to cleaning and disinfecting the healthcare environment may reduce hospital transmission of C. difficile.

Hygiene requirements for cleaning and disinfection of surfaces: recommendation of the Commission for Hospital Hygiene and Infection Prevention (KRINKO) at the Robert Koch Institute

This recommendation of the Commission for Hospital Hygiene and Infection Prevention (KRINKO) addresses not only hospitals, but also outpatient health care facilities and compiles current evidence. The following criteria are the basis for the indications for cleaning and disinfection: Infectious bioburden and tenacity of potential pathogens on surfaces and their transmission routes, influence of disinfecting surface cleaning on the rate of nosocomial infections, interruption of cross infections due to multidrug-resistant organisms, and outbreak control by disinfecting cleaning within bundles. The criteria for the selection of disinfectants are determined by the requirements for effectiveness, the efficacy spectrum, the compatibility for humans and the environment, as well as the risk potential for the development of tolerance and resistance. Detailed instructions on the organization and implementation of cleaning and disinfection measures, including structural and equipment requirements, serve as the basis for their implementation. Since the agents for surface disinfection and disinfecting surface cleaning have been classified as biocides in Europe since 2013, the regulatory consequences are explained. As possible addition to surface disinfection, probiotic cleaning, is pointed out. In an informative appendix (only in German), the pathogen characteristics for their acquisition of surfaces, such as tenacity, infectious dose and biofilm formation, and the toxicological and ecotoxicological characteristics of microbicidal agents as the basis for their selection are explained, and methods for the evaluation of the resulting quality of cleaning or disinfecting surface cleaning are presented.

Concerning emergence of a new vancomycin-resistant Enterococcus faecium strain ST1299/CT1903/vanA at a tertiary university centre in South Germany

BACKGROUND

vanB-carrying vancomycin-resistant Enterococcus faecium (VREfm) of the sequence types 80 (ST80) and ST117 have dominated Germany in the past. In 2020, our hospital witnessed a sharp increase in the proportion of vanA-positive VREfm.

AIM

To attempt to understand these dynamics through whole-genome sequencing (WGS) and analysis of nosocomial transmissions.

METHODS

At our hospital, the first VREfm isolate per patient, treated during 2020, was analysed retrospectively using specific vanA/vanB PCR, WGS, multi-locus sequence typing (MLST), and core-genome (cg) MLST. Epidemiologic links between VRE-positive patients were assessed using hospital occupancy data.

FINDINGS

Isolates from 319 out of 356 VREfm patients were available for WGS, of which 181 (56.7%) fulfilled the ECDC definition for nosocomial transmission. The high load of nosocomial cases is reflected in the overall high clonality rate with only three dominating sequence (ST) and complex types (CT), respectively: the new emerging strain ST1299 (100% vanA, 77.4% CT1903), and the well-known ST80 (90.0% vanB, 81.0% CT1065) and ST117 (78.0% vanB, 65.0% CT71). The ST1299 isolates overall, and the subtype CT1903 in particular, showed high isolate clonality, which demonstrates impressively high spreading potential. Overall, 152 out of 319 isolates had an allelic cgMLST difference of ≤3 to another, including 91 (59.6%) ST1299. Occupancy data identified shared rooms (3.7%), shared departments (6.2%), and VRE-colonized prior room occupants (0.6%) within 30 days before diagnosis as solid epidemiological links.

CONCLUSION

A new emerging VREfm clone, ST1299/CT1903/vanA, dominated our institution in 2020 and has been an important driver of the increasing VREfm rates.

Risk of organism acquisition from prior room occupants: An updated systematic review

BACKGROUND

Evidence from a previous systematic review indicates that patients admitted to a room where the previous occupant had a multidrug-resistant bacterial infection resulted in an increased risk of subsequent colonisation and infection with the same organism for the next room occupant. In this paper, we have sought to expand and update this review.

METHODS

A systematic review and meta-analysis was undertaken. A search using Medline/PubMed, Cochrane and CINHAL databases was conducted. Risk of bias was assessed by the ROB-2 tool for randomised control studies and ROBIN-I for non-randomised studies.

RESULTS

From 5175 identified, 12 papers from 11 studies were included in the review for analysis. From 28,299 patients who were admitted into a room where the prior room occupant had any of the organisms of interest, 651 (2.3%) were shown to acquire the same species of organism. In contrast, 981,865 patients were admitted to a room where the prior occupant did not have an organism of interest, 3818 (0.39%) acquired an organism(s). The pooled acquisition odds ratio (OR) for all the organisms across all studies was 2.45 (95% CI: 1.53-3.93]. There was heterogeneity between the studies (I2 89%, P < 0.001).

CONCLUSION

The pooled OR for all the pathogens in this latest review has increased since the original review. Findings from our review provide some evidence to help inform a risk management approach when determining patient room allocation. The risk of pathogen acquisition appears to remain high, supporting the need for continued investment in this area.

Length of intensive care unit stay and the apparent efficacy of antimicrobial-based versus non-antimicrobial-based ventilator pneumonia prevention interventions within the Cochrane review database

BACKGROUND

The risk of acquiring ventilator-associated pneumonia (VAP) increases with intensive care unit (ICU) length of stay (LOS). The objectives here are to estimate, using data derived from randomized concurrent control trials (RCCTs) of non-antimicrobial versus antimicrobial interventions, the relation of LOS with firstly, apparent VAP prevention effect, and secondly, with VAP incidence in control and intervention groups.

METHODS

Control and intervention group data derived from 13 Cochrane reviews of 78 RCCTs of antimicrobial-based interventions versus 111 RCCTs of various non-antimicrobial-based VAP prevention interventions.

RESULTS

In meta-regression models of VAP prevention effect versus group mean LOS, the effect size of non-antimicrobial-based interventions regress towards the null (+0.028; +0.002 to +0.054) whereas antimicrobial-based interventions regress away from the null (-0.043; -0.08 to -0.004). The day 9-10 VAP incidence increase is 1.28 (0.97-1.6) percentage points among the control groups of antimicrobial interventions per day. By contrast, these increases among antimicrobial- (0.45; 0.19-0.71) and non-antimicrobial- (0.58; 0.29-0.87) intervention groups and in control groups of non-antimicrobial- (0.76; 0.46-1.05) interventions are all similar.

CONCLUSIONS

Antimicrobial-based versus non-antimicrobial-based interventions show overall greater apparent VAP prevention which is most apparent with longer group mean LOS. The basis for this surprising relationship with LOS resides, paradoxically, within the control rather than the intervention groups. This discrepancy implicates indirect (spill-over) effects, inapparent within individual antimicrobial-based RCCTs, which could spuriously conflate the appearance of VAP prevention.

Risk of multi-drug-resistant organism acquisition from prior bed occupants in the intensive care unit: a meta-analysis

Multi-drug-resistant organisms (MDROs) have become a global threat to human health. Prior bed occupancy with MDRO infection/colonization is an exposure factor that is closely associated with the MDRO acquisition rates in subsequent bed patients in intensive care units (ICUs). A meta-analysis was conducted to investigate the risk of MDRO acquisition from prior bed occupants in the ICU. PubMed, Cochrane Library, Web of Science, and Embase databases and reference lists were searched for articles published up to December 2021. The Newcastle-Ottawa scale was used for quality assessment. The risk measure was calculated as the odds ratio (OR) and corresponding 95% confidence interval (CI), and the heterogeneity was tested using I2 method and Q test. Eight articles were analysed using a random-effects model. Of the 8147 patients exposed to prior bed occupants infected or colonized with MDROs, 421 had acquired MDROs. The control group consisted of 55,933 patients without exposure factors, of which 1768 had been infected/colonized with MDROs. The pooled acquisition OR for MDROs was 1.80 (95% CI: 1.42, 2.29), P<0.00001. Subgroup analysis based on multi-drug-resistant Gram-positive and Gram-negative organisms was conducted using a fixed-effects model. The results significantly varied between the groups. Heterogeneity was partially explained by the MDRO type. In conclusion, exposure of bed occupants to infected/colonized MDROs significantly increased the risk of MDRO acquisition in subsequent bed occupants.

Multimodal environmental cleaning strategies to prevent healthcare-associated infections

Infection transmission in healthcare is multifaceted and by in large involves the complex interplay between a pathogen, a host and their environment. To prevent transmission, infection prevention strategies must also consider these complexities and incorporate targeted interventions aimed at all possible transmission pathways. One strategy to prevent and control infection is environmental cleaning. There are many aspects to an environmental cleaning strategy. We believe the key to successfully reducing the risk of healthcare-associated infections through the environment, is to design and implement a multimodal intervention. This paper aims to provide an overview of important considerations for designing a meaningful and sustainable environmental program for healthcare facilities.

Hospital cleaning: past, present, and future

INTRODUCTION

The importance of hospital cleaning for controlling healthcare-associated infection (HAI) has taken years to acknowledge. This is mainly because the removal of dirt is inextricably entwined with gender and social status, along with lack of evidence and confusion over HAI definitions. Reducing so-called endogenous infection due to human carriage entails patient screening, decolonisation and/or prophylaxis, whereas adequate ventilation, plumbing and cleaning are needed to reduce exogenous infection. These infection types remain difficult to separate and quantitate. Patients themselves demonstrate wide-ranging vulnerability to infection, which further complicates attempted ranking of control interventions, including cleaning. There has been disproportionate attention towards endogenous infection with less interest in managing environmental reservoirs.

QUANTIFYING CLEANING AND CLEANLINESS

Finding evidence for cleaning is compromised by the fact that modelling HAI rates against arbitrary measurements of cleaning/cleanliness requires universal standards and these are not yet established. Furthermore, the distinction between cleaning (soil removal) and cleanliness (soil remaining) is usually overlooked. Tangible bench marking for both cleaning methods and all surface types within different units, with modification according to patient status, would be invaluable for domestic planning, monitoring and specification.

AIMS AND OBJECTIVES

This narrative review will focus on recent history and current status of cleaning in hospitals. While its importance is now generally accepted, cleaning practices still need attention in order to determine how, when and where to clean. Renewed interest in removal and monitoring of surface bioburden would help to embed risk-based practice in hospitals across the world.

Potential sources of contamination on textiles and hard surfaces identified as high-touch sites near the patient environment

The hospital environment represents an important mediator for the transmission of healthcare-associated infections through direct and indirect hand contact with hard surfaces and textiles. In this study, bacteria on high-touch sites, including textiles and hard surfaces in two care wards in Sweden, were identified using microbiological culture methods and 16S rDNA sequencing. During a cross-sectional study, 176 high-touch hard surfaces and textiles were identified and further analysed using microbiological culture for quantification of total aerobic bacteria, Staphylococcus aureus, Clostridium difficile and Enterobacteriacae. The bacterial population structures were further analysed in 26 samples using 16S rDNA sequencing. The study showed a higher frequency of unique direct hand-textile contacts (36 per hour), compared to hard surfaces (2.2 per hour). Hard surfaces met the recommended standard of ≤ 5 CFU/cm2 for aerobic bacteria and ≤ 1 CFU/cm2 for S. aureus (53% and 35%, respectively) to a higher extent compared to textiles (19% and 30%, respectively) (P = 0.0488). The number of bacterial genera was higher on textiles than on the hard surfaces. Staphylococcus (30.4%) and Corynebacterium (10.9%) were the most representative genera for textiles and Streptococcus (13.3%) for hard surfaces. The fact that a big percentage of the textiles did not fulfil the criteria for cleanliness, combined with the higher bacterial diversity, compared to hard surfaces, are indicators that textiles were bacterial reservoirs and potential risk vectors for bacterial transmission. However, since most of the bacteria found in the study belonged to the normal flora, it was not possible to draw conclusions of textiles and hard surfaces as sources of healthcare associated infections.

Tolerance of clinical vancomycin-resistant Enterococcus faecium isolates against UV-C light from a mobile source

BACKGROUND

Admission to a room previously occupied by patients carrying environmentally robust pathogens implies an increased risk of acquiring those pathogens. Therefore, 'No-touch' automated room disinfection systems, including devices based on UV-C irradiation, are discussed to improve terminal cleaning. It is still unclear if clinical isolates of relevant pathogens behave differently under UV-C irradiation compared to laboratory strains used in the approval process of disinfection procedures. In this study we analysed the susceptibility of well characterized clonally divergent vancomycin-resistant enterococci (VRE) strains, including a linezolid-resistant isolate, against UV-C radiation.

METHODS

Susceptibility against UV-C of ten clonally divergent clinical isolates of VRE was determined in comparison to the commonly used test organism Enterococcus hirae ATCC 10541. Ceramic tiles contaminated with 105 to 106 colony forming units/25 cm² of the different enterococci were positioned at a distance of 1.0 and 1.5 m and irradiated for 20 s, resulting in a UV-C dose of 50 and 22 mJ/cm², respectively. Reduction factors were calculated after quantitative culture of the bacteria recovered from treated and untreated surfaces.

RESULTS

Susceptibility to UV-C varied considerably among the strains studied, with the mean value of the most robust strain being up to a power of ten lower compared to the most sensitive strain at both UV-C doses. The two most tolerant strains belonged to MLST sequence types ST80 and ST1283. The susceptibility of the laboratory strain E. hirae ATCC 10541 ranged between the most sensitive and most tolerant isolates for both irradiation doses. However, for UV-C dose of 22 mJ/cm², the reduction of the most tolerant isolate of ST1283 was statistically significantly lower compared to E. hirae ATCC 10541. The most susceptible strains belonged to the MLST sequence types ST117 and ST203.

CONCLUSIONS

These results indicate that UV-C doses reported in the literature are sufficient for the reduction of commonly used reference strains of enterococci but could be insufficient for the reduction of tolerant patient VRE-isolates in a hospital setting. Therefore, for future studies, the most tolerant clinical isolates should be used to validate automated UV-C devices or longer exposure times should be expected to ensure efficacy in the real world.

Surface Disinfection Practice in Public Hospitals in the Era of COVID-19: Assessment of Disinfectant Solution Preparation and Use in Addis Ababa, Ethiopia

Background

Surface disinfection of healthcare facilities with appropriate disinfectants is among the infection control strategies against the spread of coronavirus disease 2019 (COVID-19). As sodium hypochlorite solution (SHS) is a commonly used surface disinfectant, its preparation and proper use should be given a due attention. The current study aimed at assessing the practice of Addis Ababa public hospitals in the preparation and use of SHS.

Methods

A cross-sectional observational study was employed to assess the adequacy of disinfectant solution preparation and use. Checklists were used for data collection. Descriptive statistics were used for data analyses, and categorical variables were described by frequencies and percentages.

Results

Out of the twelve public hospitals included in the study; only three hospitals checked the potency of the working SHS. Majority of the hospitals (8 hospitals) stored the concentrated SHS products in cool, dry, and direct sunlight protected places. It was only in one hospital where appropriate personal protective equipment was used during the preparation and quality control activities. Surfaces were not cleaned in all hospitals before disinfection; and the rooms were ventilated only in 2 hospitals during the application of the disinfectant solution.

Conclusion

The study revealed that the preparations of SHS in the public hospitals did not comply with most of the requirements of good compounding practice. Moreover, standard practices were not maintained in majority hospitals during the use of SHS for surface disinfection. As a control strategy in the spread of COVID-19 and other infections, appropriate corrective actions shall be implemented in the studied hospitals to mitigate the limitations observed in the preparation and use of SHS.

Establishing the safety of selective digestive decontamination within the ICU population: a bridge too far?

BACKGROUND

Infection prevention interventions within the intensive care unit (ICU) setting, whether studied within quality improvement projects or cluster randomized trials (CRT), are seen as low risk and grounded in an ethical imperative. Selective digestive decontamination (SDD) appears highly effective at preventing ICU infections within randomized concurrent control trials (RCCTs) prompting mega-CRTs with mortality as the primary endpoint.

FINDINGS

Surprisingly, the summary results of RCCTs versus CRTs differ strikingly, being respectively, a 15-percentage-point versus a zero-percentage-point ICU mortality difference between control versus SDD intervention groups. Multiple other discrepancies are equally puzzling and contrary to both prior expectations and the experience within population-based studies of infection prevention interventions using vaccines. Could spillover effects from SDD conflate the RCCT control group event rate differences and represent population harm? Evidence that SDD is fundamentally safe to concurrent non-recipients in ICU populations is absent. A postulated CRT to realize this, the SDD Herd Effects Estimation Trial (SHEET), would require > 100 ICUs to achieve sufficient statistical power to find a two-percentage-point mortality spillover effect. Moreover, as a potentially harmful population-based intervention, SHEET would pose novel and insurmountable ethical issues including who is the research subject; whether informed consent is required and from whom; whether there is equipoise; the benefit versus the risk; considerations of vulnerable groups; and who should be the gatekeeper?

CONCLUSION

The basis for the mortality difference between control and intervention groups of SDD studies remains unclear. Several paradoxical results are consistent with a spillover effect that would conflate the inference of benefit originating from RCCTs. Moreover, this spillover effect would constitute to herd peril.

Environmental contamination with highly resistant microorganisms after relocating to a new hospital building with 100% single-occupancy rooms: A prospective observational before-and-after study with a three-year follow-up

INTRODUCTION

Inanimate surfaces within hospitals can be a source of transmission for highly resistant microorganisms (HRMO). While many hospitals are transitioning to single-occupancy rooms, the effect of single-occupancy rooms on environmental contamination is still unknown. We aimed to determine differences in environmental contamination with HRMO between an old hospital building with mainly multiple-occupancy rooms and a new hospital building with 100% single-occupancy rooms, and the environmental contamination in the new hospital building during three years after relocating.

METHODS

Environmental samples were taken twice in the old hospital, and fifteen times over a three-year period in the new hospital. Replicate Organism Direct Agar Contact-plates (RODACs) were used to determine colony forming units (CFU). Cotton swabs premoistened with PBS were used to determine presence of methicillin-resistant Staphylococcus aureus, carbapenemase-producing Pseudomonas aeruginosa, highly resistant Enterobacterales, carbapenem-resistant Acinetobacter baumannii, and vancomycin-resistant Enterococcus faecium. All identified isolates were subjected to whole genome sequencing (WGS) using Illumina technology.

RESULTS

In total, 4993 hospital sites were sampled, 724 in the old and 4269 in the new hospital. CFU counts fluctuated during the follow-up period in the new hospital building, with lower CFU counts observed two- and three years after relocating, which was during the COVID-19 pandemic. The CFU counts in the new building were equal to or surpassed the CFU counts in the old hospital building. In the old hospital building, 24 (3.3%) sample sites were positive for 49 HRMO isolates, compared to five (0.1%) sample sites for seven HRMO isolates in the new building (P < 0.001). In the old hospital, 89.8% of HRMO were identified from the sink plug. In the new hospital, 71.4% of HRMO were identified from the shower drain, and no HRMO were found in sinks.

DISCUSSION

Our results indicate that relocating to a new hospital building with 100% single-occupancy rooms significantly decreases HRMO in the environment. Given that environmental contamination is an important source for healthcare associated infections, this finding should be taken into account when considering hospital designs for renovations or the construction of hospitals.

Not in their hands only: hospital hygiene, evidence and collective moral responsibility

Hospital acquired infections (HAIs) are a major threat to patient safety. This paper addresses the following question: given what is known about the causes of and possible interventions on HAIs, to whom or what should the moral responsibility for preventing these infections be attributed? First, we show how generating robust evidence on the effectiveness of preventive hygiene measures is a complex endeavour and review the existing evidence on the causes of HAIs. Second, we demonstrate that the existing literature on the ethical aspects of infection control has focused on responsibility at the individual-level. Thirdly, we argue that these accounts do not accommodate systemic factors relevant for HAI prevention. We show that the notion of collective responsibility is useful for making understandable how systemic factors, such as employment conditions in hospitals, are both causally and ethically relevant in infection control.

A randomised controlled trial investigating the effect of improving the cleaning and disinfection of shared medical equipment on healthcare-associated infections: the CLEaning and Enhanced disiNfection (CLEEN) study

BACKGROUND

Healthcare-associated infections (HAIs) are a common, costly, yet largely preventable complication impacting patients in healthcare settings globally. Improving routine cleaning and disinfection of the hospital environment has been shown to reduce the risk of HAI. Contaminated shared medical equipment presents a primary transmission route for infectious pathogens, yet is rarely studied. The CLEEN study will assess how enhanced cleaning and disinfection of shared medical equipment affects the rate of HAIs in a tertiary hospital setting. The initiative is an evidence-based approach combining staff training, auditing and feedback to environmental services staff to enhance cleaning and disinfection practices.

METHODS

The CLEEN study will use a stepped wedge randomised controlled design in 10 wards of one large Australian hospital over 36 weeks. The intervention will consist of 3 additional hours per weekday for the dedicated cleaning and disinfection of shared medical equipment on each ward. The primary outcome is to demonstrate the effectiveness of improving the quality and frequency of cleaning shared medical equipment in reducing HAIs, as measured by a HAI point prevalence study (PPS). The secondary outcomes include the thoroughness of equipment cleaning assessed using fluorescent marker technology and the cost-effectiveness of the intervention.

DISCUSSION

Evidence from the CLEEN study will contribute to future policy and practice guidelines about the cleaning and disinfection of shared medical equipment. It will be used by healthcare leaders and clinicians to inform decision-making and implementation of best-practice infection prevention strategies to reduce HAIs in healthcare facilities.

TRIAL REGISTRATION

Australia New Zealand Clinical Trial Registry ACTRN12622001143718.

Evaluation of daily environmental cleaning and disinfection practices in veterans affairs acute and long-term care facilities: A mixed methods study

OBJECTIVES

To describe daily environmental cleaning and disinfection practices and their associations with cleaning rates while exploring contextual factors experienced by healthcare workers involved in the cleaning process.

METHODS

A convergent mixed methods approach using quantitative observations (ie, direct observation of environmental service staff performing environmental cleaning using a standardized observation form) and qualitative interviews (ie, semistructured interviews of key healthcare workers) across 3 Veterans Affairs acute and long-term care facilities.

RESULTS

Between December 2018 and May 2019 a total of sixty-two room observations (N = 3602 surfaces) were conducted. The average observed surface cleaning rate during daily cleaning in patient rooms was 33.6% for all environmental surfaces and 60.0% for high-touch surfaces (HTS). Higher cleaning rates were observed with bathroom surfaces (Odds Ratio OR = 3.23), HTSs (OR = 1.57), and reusable medical equipment (RME) (OR = 1.40). Lower cleaning rates were observed when cleaning semiprivate rooms (OR = 0.71) and rooms in AC (OR = 0.56). In analysis stratified by patient presence (ie, present, or absent) in the room during cleaning, patient absence was associated with higher cleaning rates for HTSs (OR = 1.71). In addition, the odds that bathroom surfaces being cleaned more frequently than bedroom surfaces decreased (OR = 1.97) as well as the odds that private rooms being cleaned more frequently than semi-private rooms also decreased (OR = 0.26; 0.07-0.93). Between January and June 2019 eighteen qualitative interviews were conducted and found key themes (ie, patient presence and semiprivate rooms) as potential barriers to cleaning; this supports findings from the quantitative analysis.

CONCLUSION

Overall observed rates of daily cleaning of environmental surfaces in both acute and long-term care was low. Standardized environmental cleaning practices to address known barriers, specifically cleaning practices when patients are present in rooms and semi-private rooms are needed to achieve improvements in cleaning rates.

Effectiveness of Ultraviolet-C Disinfection on Hospital-Onset Gram-Negative Rod Bloodstream Infection: A Nationwide Stepped-Wedge Time-Series Analysis

BACKGROUND

The effectiveness of enhanced terminal room cleaning with ultraviolet C (UV-C) disinfection in reducing gram-negative rod (GNR) infections has not been well evaluated. We assessed the association of implementation of UV-C disinfection systems with incidence rates of hospital-onset (HO) GNR bloodstream infection (BSI).

METHODS

We obtained information regarding UV-C use and the timing of implementation through a survey of all Veterans Health Administration (VHA) hospitals providing inpatient acute care. Episodes of HO-GNR BSI were identified between January 2010 and December 2018. Bed days of care (BDOC) was used as the denominator. Over-dispersed Poisson regression models were fitted with hospital-specific random intercept, UV-C disinfection use for each month, baseline trend, and seasonality as explanatory variables. Hospitals without UV-C use were also included to the analysis as a nonequivalent concurrent control group.

RESULTS

Among 128 VHA hospitals, 120 provided complete survey responses with 40 reporting implementations of UV-C systems. We identified 13 383 episodes of HO-GNR BSI and 24 141 378 BDOC. UV-C use was associated with a lower incidence rate of HO-GNR BSI (incidence rate ratio: 0.813; 95% confidence interval: .656-.969; P = .009). There was wide variability in the effect size of UV-C disinfection use among hospitals.

CONCLUSIONS

In this large quasi-experimental analysis within the VHA System, enhanced terminal room cleaning with UV-C disinfection was associated with an approximately 19% lower incidence of HO-GNR BSI, with wide variability in effectiveness among hospitals. Further studies are needed to identify the optimal implementation strategy to maximize the effectiveness of UV-C disinfection technology.

Innovation for infection prevention and control-revisiting Pasteur's vision

Louis Pasteur has long been heralded as one of the fathers of microbiology and immunology. Less known is Pasteur's vision on infection prevention and control (IPC) that drove current infection control, public health, and much of modern medicine and surgery. In this Review, we revisited Pasteur's pioneering works to assess progress and challenges in the process and technological innovation of IPC. We focused on Pasteur's far-sighted conceptualisation of the hospital as a reservoir of microorganisms and amplifier of transmission, aseptic technique in surgery, public health education, interdisciplinary working, and the protection of health services and patients. Examples from across the globe help inform future thinking for IPC innovation, adoption, scale up and sustained use.

The Development of Technology to Prevent, Diagnose, and Manage Antimicrobial Resistance in Healthcare-Associated Infections

There is a growing risk of antimicrobial resistance (AMR) having an adverse effect on the healthcare system, which results in higher healthcare costs, failed treatments and a higher death rate. A quick diagnostic test that can spot infections resistant to antibiotics is essential for antimicrobial stewardship so physicians and other healthcare professionals can begin treatment as soon as possible. Since the development of antibiotics in the last two decades, traditional, standard antimicrobial treatments have failed to treat healthcare-associated infections (HAIs). These results have led to the development of a variety of cutting-edge alternative methods to combat multidrug-resistant pathogens in healthcare settings. Here, we provide an overview of AMR as well as the technologies being developed to prevent, diagnose, and control healthcare-associated infections (HAIs). As a result of better cleaning and hygiene practices, resistance to bacteria can be reduced, and new, quick, and accurate instruments for diagnosing HAIs must be developed. In addition, we need to explore new therapeutic approaches to combat diseases caused by resistant bacteria. In conclusion, current infection control technologies will be crucial to managing multidrug-resistant infections effectively. As a result of vaccination, antibiotic usage will decrease and new resistance mechanisms will not develop.

Results of an international pilot survey on health care environmental hygiene at the facility level

BACKGROUND

Health care-associated infections (HAIs) are a major threat to patient safety worldwide. The importance of the health care environment in patient care is not always adequately addressed. Currently, no overview exists of how health care environmental hygiene (HEH) is performed around the world.

METHODS

Our pilot survey tested a preliminary version of a framework for HEH self-assessment. It aimed to gather data to improve the framework as well as evaluate the strengths and challenges in HEH programs around the world, and across resource levels. The survey was developed by a group of experts, and based on the hand hygiene multimodal improvement strategy. The online survey was sent to 743 health care facilities (HCFs) from all of the World Bank income levels, aiming for at least 4 participants from each level. Overall responses were analyzed as a group as well as stratified per income level using OpenEpi.

RESULTS

Overall, 51 HCFs from 35 countries participated. Almost all HCFs surveyed (50/51, 98%) were found lacking in some or all of the 5 components of the WHO multimodal strategy independent of income level. The results demonstrate the widespread challenges in HEH institutions are facing around the world.

CONCLUSION

The feedback from survey participants allowed for the improvement of the self-assessment tool. There is a clear need for more focus on and investment in HEH programs in HCFs worldwide.

Understanding short-term transmission dynamics of methicillin-resistant Staphylococcus aureus in the patient room

OBJECTIVE

Little is known about the short-term dynamics of methicillin-resistant Staphylococcus aureus (MRSA) transmission between patients and their immediate environment. We conducted a real-life microbiological evaluation of environmental MRSA contamination in hospital rooms in relation to recent patient activity.

DESIGN

Observational pilot study.

SETTING

Two hospitals, hospital 1 in Zurich, Switzerland, and hospital 2 in Ann Arbor, Michigan, United States.

PATIENTS

Inpatients with MRSA colonization or infection.

METHODS

At baseline, the groin, axilla, nares, dominant hands of 10 patients and 6 environmental high-touch surfaces in their rooms were sampled. Cultures were then taken of the patient hand and high-touch surfaces 3 more times at 90-minute intervals. After each swabbing, patients' hands and surfaces were disinfected. Patient activity was assessed by interviews at hospital 1 and analysis of video footage at hospital 2. A contamination pressure score was created by multiplying the number of colonized body sites with the activity level of the patient.

RESULTS

In total, 10 patients colonized and/or infected with MRSA were enrolled; 40 hand samples and 240 environmental samples were collected. At baseline, 30% of hands and 20% of high-touch surfaces yielded MRSA. At follow-up intervals, 8 (27%) of 30 patient hands, and 10 (6%) of 180 of environmental sites were positive. Activity of the patient explained 7 of 10 environmental contaminations. Patients with higher contamination pressure score showed a trend toward higher environmental contamination.

CONCLUSION

Environmental MRSA contamination in patient rooms was highly dynamic and was likely driven by the patient's MRSA body colonization pattern and the patient activity.

Healthcare-associated infections in adult intensive care unit patients: Changes in epidemiology, diagnosis, prevention and contributions of new technologies

Patients in intensive care units (ICUs) are at high risk for healthcare-acquired infections (HAI) due to the high prevalence of invasive procedures and devices, induced immunosuppression, comorbidity, frailty and increased age. Over the past decade we have seen a successful reduction in the incidence of HAI related to invasive procedures and devices. However, the rate of ICU-acquired infections remains high. Within this context, the ongoing emergence of new pathogens, further complicates treatment and threatens patient outcomes. Additionally, the SARS-CoV-2 (COVID-19) pandemic highlighted the challenge that an emerging pathogen provides in adapting prevention measures regarding both the risk of exposure to caregivers and the need to maintain quality of care. ICU nurses hold a special place in the prevention and management of HAI as they are involved in basic hygienic care, steering and implementing quality improvement initiatives, correct microbiological sampling, and aspects antibiotic stewardship. The emergence of more sensitive microbiological techniques and our increased knowledge about interactions between critically ill patients and their microbiota are leading us to rethink how we define HAIs and best strategies to diagnose, treat and prevent these infections in the ICU. This multidisciplinary expert review, focused on the ICU setting, will summarise the recent epidemiology of ICU-HAI, discuss the place of modern microbiological techniques in their diagnosis, review operational and epidemiological definitions and redefine the place of several controversial preventive measures including antimicrobial-impregnated medical devices, chlorhexidine-impregnated washcloths, catheter dressings and chlorhexidine-based mouthwashes. Finally, general guidance is suggested that may reduce HAI incidence and especially outbreaks in ICUs.

The efficiency of cleaning in intensive care units: A systematic review

OBJECTIVES

This review aims to analyze the studies on cleaning practices and the efficiency of the cleaning carried out in environments that have a great risk of resistant microorganism infection, such as intensive care units.

METHODS

In this study, a retrospective literature review was undertaken of the relevant publications between the years 2005 and 2020, using the keywords "Cross Infection, Infection Control, Multidrug-Resistant Bacteria, Intensive Care, Room Cleaning, Environmental Cleaning, Hospital-Associated Infection"; using the international databases Pubmed, CINAHL and EBSCO and domestic database ULAKBIM on search engines. Titles and abstracts of all relevant articles found on electronic searches were reviewed by the researchers independently. The Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guideline and Patient, Intervention, Comparison, Outcomes, Study design model were used in analysing the studies.

RESULTS

The selected studies were reviewed in four main categories: Materials used in cleaning, the period between taking environmental samples, cleaning methods, and the efficiency of cleaning. Among the studies included herein, eight were randomized controlled trials, three were retrospective intervention studies, two were case-control studies and one was a retrospective cohort study.

CONCLUSIONS

Today, the assessment of cleaning in environments can be evaluated by different methods, but there are advantages and disadvantages of these methods. Therefore, in the relevant literature, it is suggested that cleaning must be evaluated by several methods, not only one. Also, training the staff that carries out the cleaning and rewarding correct behavior by giving feedback are important approaches to increase the efficiency of cleaning. It is suggested that cleaning must be carried out every day, regularly with effective methods and equipment; frequency of cleaning during epidemics must be increased, institutions must prepare cleaning manuals according to evidence-based guidelines that are recognized at an international level.

Artificial Human Sweat as a Novel Growth Condition for Clinically Relevant Pathogens on Hospital Surfaces

The emergence of biofilms on dry hospital surfaces has led to the development of numerous models designed to challenge the efficacious properties of common antimicrobial agents used in cleaning. This is in spite of limited research defining how dry surfaces are able to facilitate biofilm growth and formation in such desiccating and nutrient-deprived environments. While it is well established that the phenotypical response of biofilms is dependent on the conditions in which they are formed, most models incorporate a nutrient-enriched, hydrated environment dissimilar to the clinical setting. In this study, we piloted a novel culture medium, artificial human sweat (AHS), which is perceived to be more indicative of the nutrient sources available on hospital surfaces, particularly those in close proximity to patients. AHS was capable of sustaining the proliferation of four clinically relevant multidrug-resistant pathogens (Acinetobacter baumannii, Staphylococcus aureus, Enterococcus faecalis, and Pseudomonas aeruginosa) and achieved biofilm formation at concentration levels equivalent to those found in situ (average, 6.00 log₁₀ CFU/cm²) with similar visual characteristics upon microscopy. The AHS model presented here could be used for downstream applications, including efficacy testing of hospital cleaning products, due to its resemblance to clinical biofilms on dry surfaces. This may contribute to a better understanding of the true impact these products have on surface hygiene. IMPORTANCE Precise modeling of dry surface biofilms in hospitals is critical for understanding their role in hospital-acquired infection transmission and surface contamination. Using a representative culture condition which includes a nutrient source is key to developing a phenotypically accurate biofilm community. This will enable accurate laboratory testing of cleaning products and their efficacy against dry surface biofilms.

Potassium Linoleate (Isomerized) Satisfies the United States Environmental Protection Agency MB-05-16 for Hospital Disinfectant on Hard, Non-porous Surfaces

Potassium conjugated linoleic acid or potassium linoleate (isomerized), 86 mM, satisfies the United States Environmental Protection Agency protocol hospital disinfectant for non-porous surfaces MB-05-16 with one-minute treatment. This stringent protocol requires separate preparations of Staphylococcus aureus (American Type Culture Collection 6538) and Pseudomonas aeruginosa (American Type Culture Collection 15442) unstirred for 48 hours, submerging 10 mm polished cylinders in the culture, and placing for 45 minutes in a 37°C humidified chamber before treating. Since potassium linoleate (isomerized) also satisfies the United States Environmental Protection Agency protocol MB-35-00 for Candida auris, this study establishes potassium linoleate (isomerized) as an effective cross-kingdom antimicrobial plant salt, soap, or cleanser. We affirm the need for formal post-treatment plating on agar to establish efficacy and not rely on OD₆₀₀ when testing for antimicrobial capacity. Aqueous dilution of the soap causes variable opalescence making optical density an unreliable marker for antimicrobial efficacy.

Impact of environmental hygiene interventions on healthcare-associated infections and patient colonization: a systematic review

BACKGROUND

Healthcare-associated infections (HAI) are one of the gravest threats to patient safety worldwide. The importance of the hospital environment has recently been revalued in infection prevention and control. Though the literature is evolving rapidly, many institutions still do not consider healthcare environmental hygiene (HEH) very important for patient safety. The evidence for interventions in the healthcare environment on patient colonization and HAI with multidrug-resistant microorganisms (MDROs) or other epidemiologically relevant pathogens was reviewed.

METHODS

We performed a systematic review according to the PRISMA guidelines using the PubMed and Web of Science databases. All original studies were eligible if published before December 31, 2019, and if the effect of an HEH intervention on HAI or patient colonization was measured. Studies were not eligible if they were conducted in vitro, did not include patient colonization or HAI as an outcome, were bundled with hand hygiene interventions, included a complete structural rebuild of the healthcare facility or were implemented during an outbreak. The primary outcome was the comparison of the intervention on patient colonization or HAI compared to baseline or control. Interventions were categorized by mechanical, chemical, human factors, or bundles. Study quality was assessed using a specifically-designed tool that considered study design, sample size, control, confounders, and issues with reporting. The effect of HEH interventions on environmental bioburden was studied as a secondary outcome.

FINDINGS

After deduplication, 952 records were scrutinized, of which 44 were included for full text assessment. A total of 26 articles were included in the review and analyzed. Most studies demonstrated a reduction of patient colonization or HAI, and all that analyzed bioburden demonstrated a reduction following the HEH intervention. Studies tested mechanical interventions (n = 8), chemical interventions (n = 7), human factors interventions (n = 3), and bundled interventions (n = 8). The majority of studies (21/26, 81%) analyzed either S. aureus, C. difficile, and/or vancomycin-resistant enterococci. Most studies (23/26, 88%) reported a decrease of MDRO-colonization or HAI for at least one of the tested organisms, while 58% reported a significant decrease of MDRO-colonization or HAI for all tested microorganisms. Forty-two percent were of good quality according to the scoring system. The majority (21/26, 81%) of study interventions were recommended for application by the authors. Studies were often not powered adequately to measure statistically significant reductions.

INTERPRETATION

Improving HEH helps keep patients safe. Most studies demonstrated that interventions in the hospital environment were related with lower HAI and/or patient colonization. Most of the studies were not of high quality; additional adequately-powered, high-quality studies are needed. Systematic registration number: CRD42020204909.

Spatiotemporal prediction of vancomycin-resistant Enterococcus colonisation

BACKGROUND

Vancomycin-resistant enterococci (VRE) is the cause of severe patient health and monetary burdens. Antibiotic use is a confounding effect to predict VRE in patients, but the antibiotic use of patients who may have frequented the same ward as the patient in question is often neglected. This study investigates how patient movements between hospital wards and their antibiotic use can explain the colonisation of patients with VRE.

METHODS

Intrahospital patient movements, antibiotic use and PCR screening data were used from a hospital in the Netherlands. The PageRank algorithm was used to calculate two daily centrality measures based on the spatiotemporal graph to summarise the flow of patients and antibiotics at the ward level. A decision tree model was used to determine a simple set of rules to estimate the daily probability of patient VRE colonisation for each hospital ward. The model performance was improved using a random forest model and compared using 30% test sample.

RESULTS

Centrality covariates summarising the flow of patients and their antibiotic use between hospital wards can be used to predict the daily colonisation of VRE at the hospital ward level. The decision tree model produced a simple set of rules that can be used to determine the daily probability of patient VRE colonisation for each hospital ward. An acceptable area under the ROC curve (AUC) of 0.755 was achieved using the decision tree model and an excellent AUC of 0.883 by the random forest model on the test set. These results confirms that the random forest model performs better than a single decision tree for all levels of model sensitivity and specificity on data not used to estimate the models.

CONCLUSION

This study showed how the movements of patients inside hospitals and their use of antibiotics could predict the colonisation of patients with VRE at the ward level. Two daily centrality measures were proposed to summarise the flow of patients and antibiotics at the ward level. An early warning system for VRE can be developed to test and further develop infection prevention plans and outbreak strategies using these results.

Phenotypic and genotypic characteristics of a Carbapenem-resistant Serratia marcescens cohort and outbreak: describing an opportunistic pathogen

Serratia marcescens is an emerging opportunistic pathogen with high genetic diversity. We described microbiological characteristics of isolates and also risk factors for infections caused by carbapenem-resistant S. marcescens(CrSm). A retrospective study of patients colonized(N=43) and infected(N=20) by CrSm over a three-year period was conducted. Polymerase chain reaction(PCR) for carbapenemases genes and molecular typing of all available strains was performed; Forty-two isolates were analyzed, including three environmental samples identified during an outbreak. Thirty-five CrSm carried bla_KPC-2; one isolate was bla_NDM-positive and four isolates carried bla_OXA-101. The genomes were grouped into three clusters with 100% bootstrap; three patterns of mutations on ompC and ompF were found. The strains carried virulence genes related to invasion and hemolysis and the environmental strains presented less mutations on the virulence genes than clinical strains. The multivariate analysis showed that previous use of polymyxin(p=0.008) was an independent risk factor for infection by CrSm. Our study highlighted that bla_KPC-2 in association with ompC, ompF mutation was the most frequent mechanism of resistance in our hospital, and that previous use of polymyxin was an independent risk factor for CrSm. There is a predominant clone, including the environmental isolates, suggesting that cross-transmission was involved in the dissemination of this pathogen.

A Meta-Analysis on Evaluation of Nosocomial Infections Amongst Patients in a Tertiary Care Hospital

Background

Hospital-acquired infections, also known as nosocomial infections, are one of the many severe outcomes amongst patients in tertiary care hospitals. Hospital-acquired influenza is amongst the most common infection which has affected huge population.

Objective

We have performed a meta-analysis in order to summarize the effects of epidemiology and clinical characteristics in HAI.

Methods

We performed literature review with help of PubMed, Cochrane Library, Embase, Scopus, Web of Science, China National Knowledge Infrastructure (CNKI), The Global Index Medicus (GIM), and other clinical databases till 2021. Many random models were used in order to obtain pooled proportions, mean difference, odds ratio, and CI.

Results

A total of six studies were analyzed, where a total of 491 nosocomial and 4030 nonnosocomial infection cases were reported. The odds ratio of mortality was 0.02 with 95% CI and the risk ration for males was 1.08 with 95% CI.

Conclusion

The proportion of nosocomial infections in cases of influenza was higher in patients admitted in tertiary care hospitals. Thus, a surveillance system for vaccination for all the high-risk patients must be made mandatory.

Risk of environmental transmission of norovirus infection from prior room occupants

BACKGROUND

Environmental contamination of norovirus (NoV) is believed to be a significant source for further transmission in hospitals.

AIM

To investigate the risk of acquiring NoV in a cleaned room previously occupied by a patient with NoV infection. The risk of having a roommate with recent NoV infection was also assessed.

METHODS

In a retrospective cohort, comprising 33,788 room stays at five infectious Disease wards in southern Sweden from 2013 to 2018, the risk of acquiring NoV infection after admission to an exposed or non-exposed room was analysed with uni- and multivariable statistical analysis, controlling for age, colonization pressure and any roommate. RNA sequencing of the NoV strains involved in suspected room transmission was also performed.

RESULTS

Five of the 1106 patients exposed to a room with a prior occupant with NoV infection and 49 in the non-exposed group acquired NoV infection. An association between NoV acquisition was found in the univariable analysis (odds ratio (OR) 3.3, P=0.01), but not when adjusting for potential confounders (OR 1.9, P=0.2). Sequencing of the NoV samples showed that only two of the five exposed patients with acquired NoV infection were infected by identical strains to the prior room occupant, inferring a room transmission risk of 0.2% (95% confidence interval 0.05-0.78%). None of the 52 patients who shared room with a roommate with NoV symptoms resolved for ≥48 h acquired NoV infection.

CONCLUSIONS

In absolute terms, the risk of room transmission of NoV is low. Discontinuation of isolation ≥48 h after resolution of symptoms seems adequate.

Long-term antimicrobial effectiveness of a silver-impregnated foil on high-touch hospital surfaces in patient rooms

Background

The hospital environment has got more attention as evidence as source for bacterial transmission and subsequent hospital-acquired infection increased. Regular cleaning and disinfection have been proposed to lower the risk of infection, in particular for gram-positive bacteria. Auto-disinfecting surfaces would allow to decrease survival of pathogens, while limiting resource to achieve a safe environment in patient rooms.

Methods

A controlled trial to evaluate the antimicrobial effectiveness of a polyvinyl chloride foil containing an integrated silver-based agent (containing silver ions 2%) on high-touch surfaces in patient rooms.

Results

The overall log reduction of the mean values was 1.8 log₁₀ CFU, the median 0.5 log₁₀ CFU comparing bioburden of control vs antimicrobial foil (p < 0.01). Important pathogens were significantly less likely recovered from the foil, in particular enterococci. These effects were present even after 6 months of in-use.

Conclusions

A foil containing an integrated silver-based agent applied to high-touch surfaces effectively results in lower recovery of important pathogens from such surfaces over a 6-month study period.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13756-021-00956-1.

Fighting Antibiotic Resistance in Hospital-Acquired Infections: Current State and Emerging Technologies in Disease Prevention, Diagnostics and Therapy

Rising antibiotic resistance is a global threat that is projected to cause more deaths than all cancers combined by 2050. In this review, we set to summarize the current state of antibiotic resistance, and to give an overview of the emerging technologies aimed to escape the pre-antibiotic era recurrence. We conducted a comprehensive literature survey of >150 original research and review articles indexed in the Web of Science using "antimicrobial resistance," "diagnostics," "therapeutics," "disinfection," "nosocomial infections," "ESKAPE pathogens" as key words. We discuss the impact of nosocomial infections on the spread of multi-drug resistant bacteria, give an overview over existing and developing strategies for faster diagnostics of infectious diseases, review current and novel approaches in therapy of infectious diseases, and finally discuss strategies for hospital disinfection to prevent MDR bacteria spread.

A Metatranscriptomics Survey of Microbial Diversity on Surfaces Post-Intervention of cleanSURFACES® Technology in an Intensive Care Unit

Hospital-acquired infections (HAIs) pose a serious threat to patients, and hospitals spend billions of dollars each year to reduce and treat these infections. Many HAIs are due to contamination from workers’ hands and contact with high-touch surfaces. Therefore, we set out to test the efficacy of a new preventative technology, AIONX^® Antimicrobial Technologies, Inc’s cleanSURFACES^®, which is designed to complement daily chemical cleaning events by continuously preventing re-colonization of surfaces. To that end, we swabbed surfaces before (Baseline) and after (Post) application of the cleanSURFACES^® at various time points (Day 1, Day 7, Day 14, and Day 28). To circumvent limitations associated with culture-based and 16S rRNA gene amplicon sequencing methodologies, these surface swabs were processed using metatranscriptomic (RNA) analysis to allow for comprehensive taxonomic resolution and the detection of active microorganisms. Overall, there was a significant (P < 0.05) global reduction of microbial diversity in Post-intervention samples. Additionally, Post sample microbial communities clustered together much more closely than Baseline samples based on pairwise distances calculated with the weighted Jaccard distance metric, suggesting a defined shift after product application. This shift was characterized by a general depletion of several microbes among Post samples, with multiple phyla also being reduced over the duration of the study. Notably, specific clinically relevant microbes, including Staphylococcus aureus, Clostridioides difficile and Streptococcus spp., were depleted Post-intervention. Taken together, these findings suggest that chemical cleaning events used jointly with cleanSURFACES^® have the potential to reduce colonization of surfaces by a wide variety of microbes, including many clinically relevant pathogens.

Predictors of missed infection control care: A tri-partite international study

AIM

This study aimed to quantify types and frequencies of missed infection control care and to develop a theoretical model for estimating nurses' consensus scores about this form of missed care.

DESIGN

A non-experimental research design using self-audit data was selected to collect information about the types and frequencies of missed infection control care from nurses employed in hospitals located in three different countries. Data collection commenced mid-year 2018.

METHODS

A multivariate approach was used to apply the consensus scores of 1.911 internationally based nurses in the missed opportunities for maintaining infection control.

RESULTS/FINDINGS

Thirteen variables exert direct effects on the nurses' total scores underpinning missed infection control care. These include the methods used to prevent hospital-acquired infections, surveillance and hand hygiene practices. Significant nurses' demographic factors also included their countries of origin, employment status, employer type, job retention intentions, work intensity, length of clinical experience and staff development attendance.

CONCLUSION

In magnitude of importance and having the largest effect on missed infection control care is missed care related to reducing hospital-acquired infections followed closely by surveillance. Missed infection control care can be quantified, and variances in its practices can be accounted by exploring the nurses' differing demographic factors, including the nurses' country of origin.

IMPACT

Variations in missed infection control care can be accounted for across three countries. While ward hygiene is underestimated by staff as a mechanism to minimize nosocomial infections, infection control surveillance remains the key to reducing hospital-acquired infections. The study's outcomes invite the use of an ongoing, whole-of-organization approach to infection control with scrutiny being needed for improved staff adherence particularly with hand hygiene.

The efficiency of cleaning in intensive care units: A systematic review

OBJECTIVES

This review aims to analyze the studies on cleaning practices and the efficiency of the cleaning carried out in environments that have a great risk of resistant microorganism infection, such as intensive care units.

METHODS

In this study, a retrospective literature review was undertaken of the relevant publications between the years 2005 and 2020, using the keywords "Cross Infection, Infection Control, Multidrug-Resistant Bacteria, Intensive Care, Room Cleaning, Environmental Cleaning, Hospital-Associated Infection"; using the international databases Pubmed, CINAHL and EBSCO and domestic database ULAKBIM on search engines. Titles and abstracts of all relevant articles found on electronic searches were reviewed by the researchers independently. The Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guideline and Patient, Intervention, Comparison, Outcomes, Study design model were used in analysing the studies.

RESULTS

The selected studies were reviewed in four main categories: Materials used in cleaning, the period between taking environmental samples, cleaning methods, and the efficiency of cleaning. Among the studies included herein, eight were randomized controlled trials, three were retrospective intervention studies, two were case-control studies and one was a retrospective cohort study.

CONCLUSIONS

Today, the assessment of cleaning in environments can be evaluated by different methods, but there are advantages and disadvantages of these methods. Therefore, in the relevant literature, it is suggested that cleaning must be evaluated by several methods, not only one. Also, training the staff that carries out the cleaning and rewarding correct behavior by giving feedback are important approaches to increase the efficiency of cleaning. It is suggested that cleaning must be carried out every day, regularly with effective methods and equipment; frequency of cleaning during epidemics must be increased, institutions must prepare cleaning manuals according to evidence-based guidelines that are recognized at an international level.

Gastrointestinal Tract Colonization Rate of Extended-Spectrum Beta-Lactamase-Producing Gram-Negative Bacteria and Associated Factors Among Orthopaedic Patients in a Tertiary Hospital in Tanzania: Implications for Infection Prevention

Background

The dual burden of road traffic accidents and antimicrobial resistance in orthopaedic infections is challenging already strained health-care systems. Limited information exists in Tanzania on antimicrobial resistance surveillance to delineate the potential sources of multi-drug-resistant bacteria for specific mitigation strategies among orthopaedic patients.

Methods

A longitudinal study was conducted at Bugando Medical Centre in Mwanza city between January and May 2020. It involved the collection of rectal swabs/stools, hand swabs, and environmental sampling to identify extended-spectrum beta-lactamase (ESBL)-producing gram-negative bacteria. Participants’ data were collected using a structured questionnaire and analysed to determine factors associated with ESBL colonization among index orthopaedic patients and correlates with other ESBL sources using OR (95% CI) and a cut-off p-value of ≤0.05.

Results

We found that 47.2% (125/265) of index patients, 77.8% (14/18) of neighbouring patients, 8.3% (2/24) of health-care workers, 72.2% (13/18) of non-medical caregivers, and 31.4% (27/86) of samples taken from the hospital environment had ESBL producers. Escherichia coli and Klebsiella spp. predominated among participants and Acinetobacter spp. predominated in the environmental samples. Patients with open fractures had increased odds of being colonized with ESBL producers [OR (95% CI): 2.08 (1.16–3.75); p=0.015]. The floor below patients’ beds was commonly contaminated; however, the odds of environmental contamination decreased on the third round of sampling [OR (95% CI: 0.16 (0.04–0.67); p=0.012], apparently as a result of parallel infection prevention and control responsive measures against coronavirus disease 2019 (COVID-19).

Conclusion

We found a high occurrence of ESBL colonization among participants and in the environmentat this tertiary hospital. The importance of routine ESBL surveillance among orthopaedic patients with open fractures on admission and strengthened decontamination of health-care premises is reiterated.

Can patient-reported room cleanliness measures predict hospital-acquired C. difficile infection? A study of acute care facilities in New York state

BACKGROUND

Patient experience measures, like those form the Hospital Consumer Assessment of Healthcare providers and Systems survey, are increasingly used in healthcare policy decisions. However, it remains unclear if these reflect quality of care, like rates of hospital-acquired infections (HAIs). This study examined the relationship between patient-reported room cleanliness, from the Hospital Consumer Assessment of Healthcare providers and Systems survey, and hospital-acquired C. difficile infection (HA-CDI) rates in NYS acute care hospitals.

METHODS

A random-effects regression analysis compared the percentage of patients indicating their room was "always" and "sometimes/never" kept clean to that facility's average HA-CDI rates, controlling for known predictors.

RESULTS

A higher percentage of patients reporting their room was "always" kept clean was associated with significantly lower rates of HA-CDI. Facilities experience 0.031 fewer cases of HA-CDI/1,000 discharges for every percentage point increase in the number of patients rating their room as "always" clean (P = .006). A higher percentage of patients reporting their room was "sometimes/never" kept clean was associated with higher rates of HA-CDI (β = 0.033), but this was not significant (P = .096).

CONCLUSIONS

These findings suggest patient perceptions of cleanliness may reflect microbial cleanliness and these measures could assist in the prevention of HAIs. However, further research is needed.

Practical recommendations for routine cleaning and disinfection procedures in healthcare institutions: a narrative review

Healthcare-associated infections (HAIs) are the most common adverse outcomes due to delivery of medical care. HAIs increase morbidity and mortality, prolong hospital stay, and are associated with additional healthcare costs. Contaminated surfaces, particularly those that are touched frequently, act as reservoirs for pathogens and contribute towards pathogen transmission. Therefore, healthcare hygiene requires a comprehensive approach whereby different strategies may be implemented together, next to targeted, risk-based approaches, in order to reduce the risk of HAIs for patients. This approach includes hand hygiene in conjunction with environmental cleaning and disinfection of surfaces and clinical equipment. This review focuses on routine environmental cleaning and disinfection including areas with a moderate risk of contamination, such as general wards. As scientific evidence has not yet resulted in universally accepted guidelines nor led to universally accepted practical recommendations pertaining to surface cleaning and disinfection, this review provides expert guidance for healthcare workers in their daily practice. It also covers outbreak situations and suggests practical guidance for clinically relevant pathogens. Key elements of environmental cleaning and disinfection, including a fundamental clinical risk assessment, choice of appropriate disinfectants and cleaning equipment, definitions for standardized cleaning processes and the relevance of structured training, are reviewed in detail with a focus on practical topics and implementation.

Evaluation of the Effectiveness of Two Automated Room Decontamination Devices Under Real-Life Conditions

To evaluate the effectiveness of automated room decontamination devices, a common aerosolized hydrogen peroxide (aHP) as well as a recent gaseous ozone-based device, which produces the disinfectant reagent without the need of consumables, were tested under real-life conditions. Twenty-two contaminated surfaces were positioned in different areas in a patient room with adjacent bathroom and anteroom. Following the decontamination process bacteria were recovered and reduction factors were calculated after performing quantitative culture. Following the manufactures instructions, the ozone-based device displayed a bactericidal effect (log10 > 5), whereas the aHP system failed for a high bacterial burden and achieves only a complete elimination of a realistic bioburden (log10 2). After increasing the exposure time to 30 min, the aHP device also reached a bactericidal effect. Nevertheless, our results indicate, that further research and development is necessary, to get knowledge about toxicity, efficacy and safety by using in complex hospital conditions and achieve meaningful integration in cleaning procedures, to reach positive effects on disinfection performance.

NeoCLEAN: a multimodal strategy to enhance environmental cleaning in a resource-limited neonatal unit

Background

Contamination of the hospital environment contributes to neonatal bacterial colonization and infection. Cleaning of hospital surfaces and equipment is seldom audited in resource-limited settings.

Methods

A quasi-experimental study was conducted to assess the impact of a multimodal cleaning intervention for surfaces and equipment in a 30-bed neonatal ward. The intervention included cleaning audits with feedback, cleaning checklists, in-room cleaning wipes and training of staff and mothers in cleaning methods. Cleaning adequacy was evaluated for 100 items (58 surfaces, 42 equipment) using quantitative bacterial surface cultures, adenosine triphosphate bioluminescence assays and fluorescent ultraviolet markers, performed at baseline (P1, October 2019), early intervention (P2, November 2019) and late intervention (P3, February 2020).

Results

Environmental swabs (55/300; 18.3%) yielded growth of 78 potential neonatal pathogens with Enterococci, S. marcescens, K. pneumoniae, S. aureus and A. baumannii predominating. Highest aerobic colony counts were noted from moist surfaces such as sinks, milk kitchen surfaces, humidifiers and suction tubing. The proportion of surfaces and equipment exhibiting no bacterial growth increased between phases (P1 = 49%, P2 = 66%, P3 = 69%; p = 0.007). The proportion of surfaces and equipment meeting the ATP “cleanliness” threshold (< 200 relative light units) increased over time (P1 = 40%, P2 = 54%, P3 = 65%; p = 0.002), as did the UV marker removal rate (P1 = 23%, P2 = 71%, P3 = 74%; p < 0.001).

Conclusion

Routine environmental cleaning of this neonatal ward was sub-optimal at baseline but improved significantly following a multimodal cleaning intervention. Involving mothers and nursing staff was key to achieving improved environmental and equipment cleaning in this resource-limited neonatal unit.

Supplementary information

The online version contains supplementary material available at 10.1186/s13756-021-00905-y.