1
|
Pereira AP, Antunes P, Peixe L, Freitas AR, Novais C. Current insights into the effects of cationic biocides exposure on Enterococcus spp. Front Microbiol 2024; 15:1392018. [PMID: 39006755 PMCID: PMC11242571 DOI: 10.3389/fmicb.2024.1392018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 06/04/2024] [Indexed: 07/16/2024] Open
Abstract
Cationic biocides (CBs), such as quaternary ammonium compounds and biguanides, are critical for controlling the spread of bacterial pathogens like Enterococcus spp., a leading cause of multidrug-resistant healthcare-associated infections. The widespread use of CBs in recent decades has prompted concerns about the potential emergence of Enterococcus spp. populations exhibiting resistance to both biocides and antibiotics. Such concerns arise from their frequent exposure to subinhibitory concentrations of CBs in clinical, food chain and diverse environmental settings. This comprehensive narrative review aimed to explore the complexity of the Enterococcus' response to CBs and of their possible evolution toward resistance. To that end, CBs' activity against diverse Enterococcus spp. collections, the prevalence and roles of genes associated with decreased susceptibility to CBs, and the potential for co- and cross-resistance between CBs and antibiotics are reviewed. Significant methodological and knowledge gaps are identified, highlighting areas that future studies should address to enhance our comprehension of the impact of exposure to CBs on Enterococcus spp. populations' epidemiology. This knowledge is essential for developing effective One Health strategies that ensure the continued efficacy of these critical agents in safeguarding Public Health.
Collapse
Affiliation(s)
- Ana P Pereira
- UCIBIO-Applied Molecular Biosciences Unit, Laboratory of Microbiology, Department of Biological Sciences, Faculty of Pharmacy, University of Porto, Porto, Portugal
- Associate Laboratory i4HB - Institute for Health and Bioeconomy, Faculty of Pharmacy, University of Porto, Porto, Portugal
| | - Patrícia Antunes
- UCIBIO-Applied Molecular Biosciences Unit, Laboratory of Microbiology, Department of Biological Sciences, Faculty of Pharmacy, University of Porto, Porto, Portugal
- Associate Laboratory i4HB - Institute for Health and Bioeconomy, Faculty of Pharmacy, University of Porto, Porto, Portugal
- Faculty of Nutrition and Food Sciences, University of Porto, Porto, Portugal
| | - Luísa Peixe
- UCIBIO-Applied Molecular Biosciences Unit, Laboratory of Microbiology, Department of Biological Sciences, Faculty of Pharmacy, University of Porto, Porto, Portugal
- Associate Laboratory i4HB - Institute for Health and Bioeconomy, Faculty of Pharmacy, University of Porto, Porto, Portugal
| | - Ana R Freitas
- UCIBIO-Applied Molecular Biosciences Unit, Laboratory of Microbiology, Department of Biological Sciences, Faculty of Pharmacy, University of Porto, Porto, Portugal
- Associate Laboratory i4HB - Institute for Health and Bioeconomy, Faculty of Pharmacy, University of Porto, Porto, Portugal
- 1H-TOXRUN, One Health Toxicology Research Unit, University Institute of Health Sciences, CESPU CRL, Gandra, Portugal
| | - Carla Novais
- UCIBIO-Applied Molecular Biosciences Unit, Laboratory of Microbiology, Department of Biological Sciences, Faculty of Pharmacy, University of Porto, Porto, Portugal
- Associate Laboratory i4HB - Institute for Health and Bioeconomy, Faculty of Pharmacy, University of Porto, Porto, Portugal
| |
Collapse
|
2
|
Rhee Y, Simms AT, Schoeny M, Baker AW, Baker MA, Gohil S, Rhee C, Talati NJ, Warren DK, Welbel S, Lolans K, Bell PB, Fukuda C, Hayden MK, Lin MY. Relationship between chlorhexidine gluconate concentration and microbial colonization of patients' skin. Infect Control Hosp Epidemiol 2024:1-6. [PMID: 38804007 DOI: 10.1017/ice.2024.81] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
OBJECTIVE To characterize the relationship between chlorhexidine gluconate (CHG) skin concentration and skin microbial colonization. DESIGN Serial cross-sectional study. SETTING/PARTICIPANTS Adult patients in medical intensive care units (ICUs) from 7 hospitals; from 1 hospital, additional patients colonized with carbapenemase-producing Enterobacterales (CPE) from both ICU and non-ICU settings. All hospitals performed routine CHG bathing in the ICU. METHODS Skin swab samples were collected from adjacent areas of the neck, axilla, and inguinal region for microbial culture and CHG skin concentration measurement using a semiquantitative colorimetric assay. We used linear mixed effects multilevel models to analyze the relationship between CHG concentration and microbial detection. We explored threshold effects using additional models. RESULTS We collected samples from 736 of 759 (97%) eligible ICU patients and 68 patients colonized with CPE. On skin, gram-positive bacteria were cultured most frequently (93% of patients), followed by Candida species (26%) and gram-negative bacteria (20%). The adjusted odds of microbial recovery for every twofold increase in CHG skin concentration were 0.84 (95% CI, 0.80-0.87; P < .001) for gram-positive bacteria, 0.93 (95% CI, 0.89-0.98; P = .008) for Candida species, 0.96 (95% CI, 0.91-1.02; P = .17) for gram-negative bacteria, and 0.94 (95% CI, 0.84-1.06; P = .33) for CPE. A threshold CHG skin concentration for reduced microbial detection was not observed. CONCLUSIONS On a cross-sectional basis, higher CHG skin concentrations were associated with less detection of gram-positive bacteria and Candida species on the skin, but not gram-negative bacteria, including CPE. For infection prevention, targeting higher CHG skin concentrations may improve control of certain pathogens.
Collapse
Affiliation(s)
- Yoona Rhee
- Division of Infectious Diseases, Rush University Medical Center, Chicago, IL, USA
| | - Andrew T Simms
- Division of Infectious Diseases, Rush University Medical Center, Chicago, IL, USA
| | - Michael Schoeny
- Department of Community, Systems and Mental Health Nursing, College of Nursing, Rush University Medical Center, Chicago, IL, USA
| | - Arthur W Baker
- Division of Infectious Diseases, Duke University School of Medicine, Durham, NC, USA
| | - Meghan A Baker
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, MA, USA
| | - Shruti Gohil
- Division of Infectious Diseases, University of California, Irvine School of Medicine, Irvine, CA, USA
| | - Chanu Rhee
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, MA, USA
| | - Naasha J Talati
- Division of Infectious Diseases, Penn Presbyterian Medical Center, University of Pennsylvania, Philadelphia, PA, USA
| | - David K Warren
- Division of Infectious Diseases, Washington University School of Medicine, St Louis, MO, USA
| | - Sharon Welbel
- Division of Infectious Diseases, Cook County Health, Chicago, IL, USA
| | - Karen Lolans
- Division of Infectious Diseases, Rush University Medical Center, Chicago, IL, USA
| | - Pamela B Bell
- Division of Infectious Diseases, Rush University Medical Center, Chicago, IL, USA
| | - Christine Fukuda
- Division of Infectious Diseases, Rush University Medical Center, Chicago, IL, USA
| | - Mary K Hayden
- Division of Infectious Diseases, Rush University Medical Center, Chicago, IL, USA
| | - Michael Y Lin
- Division of Infectious Diseases, Rush University Medical Center, Chicago, IL, USA
| |
Collapse
|
3
|
Abstract
BACKGROUND Skin antiseptics are used for several purposes before surgical procedures, for bathing high-risk patients as a means of reducing central line-associated infections and other health care associated infections. METHODS A PubMed search was performed to update the evidence on skin antiseptic products and practices. RESULTS Current guidelines for prevention of surgical site infections (SSIs) recommend preoperative baths or showers with a plain or antimicrobial soap prior to surgery, but do not make recommendations on the timing of baths, the total number of baths needed, or about the use of chlorhexidine gluconate (CGH)-impregnated cloths. Randomized controlled trials have demonstrated that pre-operative surgical hand antisepsis using an antimicrobial soap or alcohol-based hand rub yields similar SSI rates. Other studies have reported that using an alcohol-based hand rub caused less skin irritation, was easier to use, and required shorter scrub times than using antimicrobial soap. Current SSI prevention guidelines recommend using an alcohol-containing antiseptic for surgical site infection. Commonly used products contain isopropanol combined with either CHG or with povidone-iodine. Surgical site preparation protocols for shoulder surgery in men may need to include coverage for anaerobes. Several studies suggest the need to monitor and improve surgical site preparation techniques. Daily bathing of intensive care unit (ICU) patients with a CHG-containing soap reduces the incidence of central line-associated bloodstream infections (CLABSIs). Evidence for a similar effect in non-ICU patients is mixed. Despite widespread CHG bathing of ICU patients, numerous barriers to its effective implementation exist. Measuring CHG levels on the skin is useful for identifying gaps in coverage and suboptimal skin concentrations. Using alcohol-based products with at least 2% CHG for skin preparation prior to central line insertion reduces CLABSIs. CONCLUSIONS Progress has been made on skin antisepsis products and protocols, but improvements in technique are still needed.
Collapse
|
4
|
Rhee Y, Hayden MK, Schoeny M, Baker AW, Baker MA, Gohil S, Rhee C, Talati NJ, Warren DK, Welbel S, Lolans K, Bahadori B, Bell PB, Bravo H, Dangana T, Fukuda C, Bach TH, Nelson A, Simms AT, Tolomeo P, Wolf R, Yelin R, Lin MY. Impact of measurement and feedback on chlorhexidine gluconate bathing among intensive care unit patients: A multicenter study. Infect Control Hosp Epidemiol 2023; 44:1375-1380. [PMID: 37700540 PMCID: PMC10859163 DOI: 10.1017/ice.2023.177] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023]
Abstract
OBJECTIVE To assess whether measurement and feedback of chlorhexidine gluconate (CHG) skin concentrations can improve CHG bathing practice across multiple intensive care units (ICUs). DESIGN A before-and-after quality improvement study measuring patient CHG skin concentrations during 6 point-prevalence surveys (3 surveys each during baseline and intervention periods). SETTING The study was conducted across 7 geographically diverse ICUs with routine CHG bathing. PARTICIPANTS Adult patients in the medical ICU. METHODS CHG skin concentrations were measured at the neck, axilla, and inguinal region using a semiquantitative colorimetric assay. Aggregate unit-level CHG skin concentration measurements from the baseline period and each intervention period survey were reported back to ICU leadership, which then used routine education and quality improvement activities to improve CHG bathing practice. We used multilevel linear models to assess the impact of intervention on CHG skin concentrations. RESULTS We enrolled 681 (93%) of 736 eligible patients; 92% received a CHG bath prior to survey. At baseline, CHG skin concentrations were lowest on the neck, compared to axillary or inguinal regions (P < .001). CHG was not detected on 33% of necks, 19% of axillae, and 18% of inguinal regions (P < .001 for differences in body sites). During the intervention period, ICUs that used CHG-impregnated cloths had a 3-fold increase in patient CHG skin concentrations as compared to baseline (P < .001). CONCLUSIONS Routine CHG bathing performance in the ICU varied across multiple hospitals. Measurement and feedback of CHG skin concentrations can be an important tool to improve CHG bathing practice.
Collapse
Affiliation(s)
- Yoona Rhee
- Division of Infectious Diseases, Rush University Medical Center, Chicago, Illinois
| | - Mary K. Hayden
- Division of Infectious Diseases, Rush University Medical Center, Chicago, Illinois
| | - Michael Schoeny
- Department of Community, Systems, and Mental Health Nursing, College of Nursing, Rush University Medical Center, Chicago, Illinois
| | - Arthur W. Baker
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina
| | - Meghan A. Baker
- Division of Infectious Diseases, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts
| | - Shruti Gohil
- Division of Infectious Diseases, University of California, Irvine School of Medicine, Irvine, California
| | - Chanu Rhee
- Division of Infectious Diseases, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts
| | - Naasha J. Talati
- Division of Infectious Diseases, Penn Presbyterian Medical Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David K. Warren
- Division of Infectious Diseases, Washington University School of Medicine, St Louis, Missouri
| | - Sharon Welbel
- Division of Infectious Diseases, Cook County Health, Chicago, Illinois
| | - Karen Lolans
- Division of Infectious Diseases, Rush University Medical Center, Chicago, Illinois
| | - Bardia Bahadori
- Division of Infectious Diseases, University of California, Irvine School of Medicine, Irvine, California
| | - Pamela B. Bell
- Division of Infectious Diseases, Rush University Medical Center, Chicago, Illinois
| | - Heilen Bravo
- Division of Infectious Diseases, Rush University Medical Center, Chicago, Illinois
| | - Thelma Dangana
- Division of Infectious Diseases, Rush University Medical Center, Chicago, Illinois
| | - Christine Fukuda
- Division of Infectious Diseases, Rush University Medical Center, Chicago, Illinois
| | - Tracey Habrock Bach
- Division of Infectious Diseases, Washington University School of Medicine, St Louis, Missouri
| | - Alicia Nelson
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina
| | - Andrew T. Simms
- Division of Infectious Diseases, Rush University Medical Center, Chicago, Illinois
| | - Pam Tolomeo
- Division of Infectious Diseases, Penn Presbyterian Medical Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert Wolf
- Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts
| | - Rachel Yelin
- Division of Infectious Diseases, Rush University Medical Center, Chicago, Illinois
| | - Michael Y. Lin
- Division of Infectious Diseases, Rush University Medical Center, Chicago, Illinois
| |
Collapse
|
5
|
Popovich KJ, Aureden K, Ham DC, Harris AD, Hessels AJ, Huang SS, Maragakis LL, Milstone AM, Moody J, Yokoe D, Calfee DP. SHEA/IDSA/APIC Practice Recommendation: Strategies to prevent methicillin-resistant Staphylococcus aureus transmission and infection in acute-care hospitals: 2022 Update. Infect Control Hosp Epidemiol 2023; 44:1039-1067. [PMID: 37381690 PMCID: PMC10369222 DOI: 10.1017/ice.2023.102] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 05/03/2023] [Indexed: 06/29/2023]
Abstract
Previously published guidelines have provided comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute-care hospitals in implementing and prioritizing efforts to prevent methicillin-resistant Staphylococcus aureus (MRSA) transmission and infection. This document updates the "Strategies to Prevent Methicillin-Resistant Staphylococcus aureus Transmission and Infection in Acute Care Hospitals" published in 2014.1 This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA). It is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the Association for Professionals in Infection Control and Epidemiology (APIC), the American Hospital Association (AHA), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.
Collapse
Affiliation(s)
- Kyle J. Popovich
- Department of Internal Medicine, RUSH Medical College, Chicago, Illinois
| | - Kathy Aureden
- Infection Prevention, Advocate Aurora Health, Downers Grove, Illinois
| | - D. Cal Ham
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Anthony D. Harris
- Health Care Outcomes Research, University of Maryland School of Medicine, Baltimore, Maryland
| | - Amanda J. Hessels
- Columbia School of Nursing, New York, New York
- Hackensack Meridian Health, Edison, New Jersey
| | - Susan S. Huang
- Division of Infectious Diseases, University of California Irvine School of Medicine, Irvine, California
| | - Lisa L. Maragakis
- Johns Hopkins University School of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Aaron M. Milstone
- Division of Pediatric Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Julia Moody
- Infection Prevention, HCA Healthcare, Nashville, Tennessee
| | - Deborah Yokoe
- Department of Medicine, University of California San Francisco School of Medicine, San Francisco, California
- Transplant Infectious Diseases, UCSF Medical Center, San Francisco, California
| | - David P. Calfee
- Department of Medicine, Weill Cornell Medicine, New York, New York
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York
| |
Collapse
|
6
|
Brindle T. Horizontal approaches to infection prevention: daily chlorhexidine gluconate bathing. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2023; 32:502-507. [PMID: 37289709 DOI: 10.12968/bjon.2023.32.11.502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Healthcare-associated infections (HAIs) pose a significant challenge in hospitals. Infection control strategies have been widely employed to mitigate their incidence. In hospitals, chlorhexidine gluconate (CHG) solutions are commonly used as antiseptic skin cleansers as part of comprehensive infection prevention bundles, with daily CHG bathing being highly effective in reducing HAIs and lowering skin micro-organism density. This evidence review addresses the challenges of risk stratification in implementing CHG bathing protocols in hospitals. It highlights the benefits of a horizontal approach, where CHG bathing is implemented across the entire facility rather than being limited to specific patient populations. Evidence from systematic reviews and studies suggests that CHG bathing consistently reduces HAI rates in both intensive care unit (ICU) and non-ICU settings, supporting the adoption of a hospital-wide approach. The findings emphasise the significance of incorporating CHG bathing as part of a comprehensive approach to infection prevention in hospitals and highlight the potential for cost savings.
Collapse
Affiliation(s)
- Tod Brindle
- Global Surgical Medical Director, Mölnlycke Health Care
| |
Collapse
|
7
|
McNeil JC, Sommer LM, Vallejo JG, Hulten KG, Kaplan SL. Association of qacA/B and smr Carriage with Staphylococcus aureus Survival following Exposure to Antiseptics in an Ex Vivo Venous Catheter Disinfection Model. Microbiol Spectr 2023; 11:e0333322. [PMID: 36862001 PMCID: PMC10100659 DOI: 10.1128/spectrum.03333-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 02/01/2023] [Indexed: 03/03/2023] Open
Abstract
Many health care centers have reported an association between Staphylococcus aureus isolates bearing efflux pump genes and an elevated MIC/minimal bactericidal concentration (MBC) to chlorhexidine gluconate (CHG) and other antiseptics. The significance of these organisms is uncertain, given that their MIC/MBC is typically far lower than the CHG concentration in most commercial preparations. We sought to evaluate the relationship between carriage of the efflux pump genes qacA/B and smr in S. aureus and the efficacy of CHG-based antisepsis in a venous catheter disinfection model. S. aureus isolates with and without smr and/or qacA/B were utilized. The CHG MICs were determined. Venous catheter hubs were inoculated and exposed to CHG, isopropanol, and CHG-isopropanol combinations. The microbiocidal effect was calculated as the percent reduction in CFU following exposure to the antiseptic relative to the control. The qacA/B- and smr-positive isolates had modest elevations in the CHG MIC90 compared to the qacA/B- and smr-negative isolates (0.125 mcg/ml vs. 0.06 mcg/ml, respectively). However, the CHG microbiocidal effect was significantly lower for qacA/B- and/or smr-positive strains than for susceptible isolates, even when the isolates were exposed to CHG concentrations up to 400 μg/mL (0.04%); this finding was most notable for isolates bearing both qacA/B and smr (89.3% versus 99.9% for the qacA/B- and smr-negative isolates; P = 0.04). Reductions in the median microbiocidal effect were also observed when these qacA/B- and smr-positive isolates were exposed to a solution of 400 μg/mL (0.04%) CHG and 70% isopropanol (89.5% versus 100% for the qacA/B- and smr-negative isolates; P = 0.002). qacA/B- and smr-positive S. aureus isolates have a survival advantage in the presence of CHG concentrations exceeding the MIC. These data suggest that traditional MIC/MBC testing may underestimate the ability of these organisms to resist the effects of CHG. IMPORTANCE Antiseptic agents, including chlorhexidine gluconate (CHG), are commonly utilized in the health care environment to reduce rates of health care-associated infections. A number of efflux pump genes, including smr and qacA/B, have been reported in Staphylococcus aureus isolates that are associated with higher MICs and minimum bactericidal concentrations (MBCs) to CHG. Several health care centers have reported an increase in the prevalence of these S. aureus strains following an escalation of CHG use in the hospital environment. The clinical significance of these organisms, however, is uncertain, given that the CHG MIC/MBC is far below the concentration in commercial preparations. We present the results of a novel surface disinfection assay utilizing venous catheter hubs. We found that qacA/B-positive and smr-positive S. aureus isolates resist killing by CHG at concentrations far exceeding the MIC/MBC in our model. These findings highlight that traditional MIC/MBC testing is insufficient to evaluate susceptibility to antimicrobials acting on medical devices.
Collapse
Affiliation(s)
- J. Chase McNeil
- Department of Pediatrics, Division of Infectious Diseases, Baylor College of Medicine, Houston, Texas, USA
- Texas Children’s Hospital, Houston, Texas, USA
| | - Lauren M. Sommer
- Department of Pediatrics, Division of Infectious Diseases, Baylor College of Medicine, Houston, Texas, USA
- Texas Children’s Hospital, Houston, Texas, USA
| | - Jesus G. Vallejo
- Department of Pediatrics, Division of Infectious Diseases, Baylor College of Medicine, Houston, Texas, USA
- Texas Children’s Hospital, Houston, Texas, USA
| | - Kristina G. Hulten
- Department of Pediatrics, Division of Infectious Diseases, Baylor College of Medicine, Houston, Texas, USA
- Texas Children’s Hospital, Houston, Texas, USA
| | - Sheldon L. Kaplan
- Department of Pediatrics, Division of Infectious Diseases, Baylor College of Medicine, Houston, Texas, USA
- Texas Children’s Hospital, Houston, Texas, USA
| |
Collapse
|
8
|
Huang W, Qiao F, Cai L, Zong Z, Zhang W. Effect of daily chlorhexidine bathing on reducing infections caused by multidrug-resistant organisms in intensive care unit patients: A semiexperimental study with parallel controls. J Evid Based Med 2023; 16:32-38. [PMID: 36779575 DOI: 10.1111/jebm.12515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 01/17/2023] [Indexed: 02/14/2023]
Abstract
OBJECTIVE To assess the effectiveness of daily bathing by chlorhexidine bathing on multidrug-resistant organisms in ICU, especially on carbapenem-resistant Acinetobacter baumannii (CRAB), carbapenem-resistant Pseudomonas aeruginosa (CRPA), and carbapenem-resistant Enterobacteriaceae (CRE). METHODS Semiexperimental study which employed both precontrols and a parallel control was conducted. In the intervention period (from July 1 to December 31, 2016), strengthened infection control measures and daily bathing with 2% CHG-impregnated wipes once daily was performed in the ICU. Fifty-seven non-ICU wards with the occurrence of multidrug-resistant organisms (MDRO) infections during the same time were selected as parallel control group (only CHG bathing was not performed). The net effect of the 2% CHG daily bathing was evaluated by the difference in difference (DID) model. RESULTS The DID model analysis showed that CHG bathing reduced the incidence of CRAB- and CRPA-caused infections in ICU by 1.56 and 2.15 cases/1000 patient days, and bathing of every 19 patients (95CI% 13 to 41) and 39 patients (95CI% 24 to 110) were able to prevent one case of HAIs of total MDROs and CRPA, respectively. However, CHG bathing showed no effect on MRSA, VRE, and CRE (p > 0.05). CONCLUSION Daily bathing with 2% CHG-impregnated wipes can reduce HAIs caused by CRAB and CRPA, while it is not effective for the prevalence of infections caused by MRSA, VRE, and CRE.
Collapse
Affiliation(s)
- Wenzhi Huang
- Institute of Hospital Management, West China Hospital, Sichuan University, Chengdu, P. R. China
- Department of Infection Control, West China Hospital, Sichuan University, Chengdu, P. R. China
| | - Fu Qiao
- Department of Infection Control, West China Hospital, Sichuan University, Chengdu, P. R. China
| | - Lin Cai
- Intensive Care Unit, West China Hospital, Sichuan University, Chengdu, P. R. China
| | - Zhiyong Zong
- Department of Infection Control, West China Hospital, Sichuan University, Chengdu, P. R. China
- Center of Infectious Disease, West China Hospital, Sichuan University, Chengdu, P. R. China
| | - Wei Zhang
- Institute of Hospital Management, West China Hospital, Sichuan University, Chengdu, P. R. China
| |
Collapse
|
9
|
Pereira AP, Antunes P, Willems R, Corander J, Coque TM, Peixe L, Freitas AR, Novais C. Evolution of Chlorhexidine Susceptibility and of the EfrEF Operon among Enterococcus faecalis from Diverse Environments, Clones, and Time Spans. Microbiol Spectr 2022; 10:e0117622. [PMID: 35862993 PMCID: PMC9430118 DOI: 10.1128/spectrum.01176-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 06/17/2022] [Indexed: 11/20/2022] Open
Abstract
Chlorhexidine (CHX) is widely used to control the spread of pathogens (e.g., human/animal clinical settings, ambulatory care, food industry). Enterococcus faecalis, a major nosocomial pathogen, is broadly distributed in diverse hosts and environments facilitating its exposure to CHX over the years. Nevertheless, CHX activity against E. faecalis is understudied. Our goal was to assess CHX activity and the variability of ChlR-EfrEF proteins (associated with CHX tolerance) among 673 field isolates and 1,784 E. faecalis genomes from the PATRIC database from different sources, time spans, clonal lineages, and antibiotic-resistance profiles. The CHX MIC (MICCHX) and minimum bactericidal concentration (MBCCHX) against E. faecalis presented normal distributions (0.5 to 64 mg/L). However, more CHX-tolerant isolates were detected in the food chain and recent human infections, suggesting an adaptability of E. faecalis populations in settings where CHX is heavily used. Heterogeneity in ChlR-EfrEF sequences was identified, with isolates harboring incomplete ChlR-EfrEF proteins, particularly the EfrE identified in the ST40 clonal lineage, showing low MICCHX (≤1mg/L). Distinct ST40-E. faecalis subpopulations carrying truncated and nontruncated EfrE were detected, with the former being predominant in human isolates. This study provides a new insight about CHX susceptibility and ChlR-EfrEF variability within diverse E. faecalis populations. The MICCHX/MBCCHX of more tolerant E. faecalis (MICCHX = 8 mg/L; MBCCHX = 64 mg/L) remain lower than in-use concentrations of CHX (≥500 mg/L). However, increased CHX use, combined with concentration gradients occurring in diverse environments, potentially selecting multidrug-resistant strains with different CHX susceptibilities, signals the importance of monitoring the trends of E. faecalis CHX tolerance within a One Health approach. IMPORTANCE Chlorhexidine (CHX) is a disinfectant and antiseptic used since the 1950s and included in the World Health Organization's list of essential medicines. It has been widely applied in hospitals, the community, the food industry, animal husbandry and pets. CHX tolerance in Enterococcus faecalis, a ubiquitous bacterium and one of the leading causes of human hospital-acquired infections, remains underexplored. Our study provides novel and comprehensive insights about CHX susceptibility within the E. faecalis population structure context, revealing more CHX-tolerant subpopulations from the food chain and recent human infections. We further show a detailed analysis of the genetic diversity of the efrEF operon (previously associated with E. faecalis CHX tolerance) and its correlation with CHX phenotypes. The recent strains with a higher tolerance to CHX and the multiple sources where bacteria are exposed to this biocide alert us to the need for the continuous monitoring of E. faecalis adaptation toward CHX tolerance within a One Health approach.
Collapse
Affiliation(s)
- Ana P. Pereira
- UCIBIO-Applied Molecular Biosciences Unit, Laboratory of Microbiology, Department of Biological Sciences, REQUIMTE Faculty of Pharmacy, University of Porto, Porto, Portugal
- Associate Laboratory i4HB, Institute for Health and Bioeconomy, Faculty of Pharmacy, University of Porto, Porto, Portugal
| | - Patrícia Antunes
- UCIBIO-Applied Molecular Biosciences Unit, Laboratory of Microbiology, Department of Biological Sciences, REQUIMTE Faculty of Pharmacy, University of Porto, Porto, Portugal
- Associate Laboratory i4HB, Institute for Health and Bioeconomy, Faculty of Pharmacy, University of Porto, Porto, Portugal
- Faculty of Nutrition and Food Sciences, University of Porto, Porto, Portugal
| | - Rob Willems
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jukka Corander
- Department of Biostatistics, Faculty of Medicine, University of Oslo, Oslo, Norway
- Parasites and Microbes, Wellcome Sanger Institute, Cambridge, United Kingdom
- Helsinki Institute of Information Technology, Department of Mathematics and Statistics, University of Helsinki, Helsinki, Finland
| | - Teresa M. Coque
- Servicio de Microbiologia, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Centro de Investigación Biomédica en Enfermedades Infecciosas (CIBER-EII), Madrid, Spain
| | - Luísa Peixe
- UCIBIO-Applied Molecular Biosciences Unit, Laboratory of Microbiology, Department of Biological Sciences, REQUIMTE Faculty of Pharmacy, University of Porto, Porto, Portugal
- Associate Laboratory i4HB, Institute for Health and Bioeconomy, Faculty of Pharmacy, University of Porto, Porto, Portugal
| | - Ana R. Freitas
- UCIBIO-Applied Molecular Biosciences Unit, Laboratory of Microbiology, Department of Biological Sciences, REQUIMTE Faculty of Pharmacy, University of Porto, Porto, Portugal
- Associate Laboratory i4HB, Institute for Health and Bioeconomy, Faculty of Pharmacy, University of Porto, Porto, Portugal
- TOXRUN, Toxicology Research Unit, University Institute of Health Sciences, CESPU, CRL, Gandra, Portugal
| | - Carla Novais
- UCIBIO-Applied Molecular Biosciences Unit, Laboratory of Microbiology, Department of Biological Sciences, REQUIMTE Faculty of Pharmacy, University of Porto, Porto, Portugal
- Associate Laboratory i4HB, Institute for Health and Bioeconomy, Faculty of Pharmacy, University of Porto, Porto, Portugal
| |
Collapse
|
10
|
Mougeot JLC, Beckman MF, Bahrani Mougeot F, Horton JM. Cutaneous Microbiome Profiles Following Chlorhexidine Treatment in a 72-Hour Daily Follow-Up Paired Design: a Pilot Study. Microbiol Spectr 2022; 10:e0175321. [PMID: 35467392 PMCID: PMC9248901 DOI: 10.1128/spectrum.01753-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 03/18/2022] [Indexed: 01/04/2023] Open
Abstract
Venous catheter-related bloodstream infections represent a significant problem in the United States. Our objective was to determine daily changes in skin microbiome profiles up to 72h postchlorhexidine treatment. Left and right forearm skin swab samples were obtained from 10 healthy volunteers over 72h at 24h intervals. Dorsal surface of left arm was treated with chlorohexidine gluconate (CHG) at initial time point (T = 0), while the right arm remained untreated (control). Swab samples were obtained shortly before (T = 0) and after CHG treatment (T = 24-48-72h). Bacterial DNA extraction, 16S rRNA gene V1-V3 sequencing and taxonomic annotation were performed using ZymoBIOMICS pipeline. PERMANOVA, linear discriminant and bacterial interaction network analyses were performed. A total of 13 total phyla, 273 genera, and 950 total species were detected across all time points, CHG-treated or CHG-untreated. Most abundant species included Cutibacterium acnes, Staphylococcus epidermidis, and Rothia Mucilaginosa. Low biomass-related inconsistent taxa detection was observed. PERMANOVA suggested a marginal difference between CHG-treated and CHG-untreated microbiome profiles (Genera: P(perm) = 0.0531; Species: P(perm) = 0.0450). Bacterial interaction network guided PERMANOVA analyses detected a microbiome change over time, suggesting a consistent CHG treatment-specific change. LEfSe identified Finegoldia magna, Bacillus pumilus, Bacillus thermoamylovorans as the only distinctive species. These species were more abundant and/or present post-CHG treatment in the CHG-treated group. These findings suggest that the skin microbiome was not significantly different 24, 48, or 72h after CHG treatment. Previous culture-based studies have found similar results after 24h. Future studies will be needed to determine the mechanisms of bacterial regrowth after CHG treatment. IMPORTANCE Annually, over 80,000 central line infections occur in the United States. Understanding the pathogenesis of these infections is crucial. Chlorhexidine is the most commonly used skin preparation before line placement. We hypothesized that the use of chlorhexidine and dressings will alter the normal arm skin microbiome over a period of 72h. We used 16S-rRNA gene next generation sequencing (NGS) to determine the forearm skin microbiome of volunteers. The left arm was swabbed with chlorhexidine and the right arm served as control. The skin microbiome returned to normal after 24h. Our NGS results confirm findings of two previous culture-based studies. Relative abundance of Bacillus spp. in the chlorhexidine-treated samples was increased, consistent with one previous study. Based on the results of this pilot study, we will need to measure viable bacteria during a 24h time course following chlorhexidine treatment to understand the source of skin microbiome replenishment.
Collapse
Affiliation(s)
| | | | | | - James M. Horton
- Carolinas Medical Center, Atrium Health, Charlotte, North Carolina, USA
| |
Collapse
|
11
|
Kakadia PG, Conway BR. Nanoemulsions for Enhanced Skin Permeation and Controlled Delivery of Chlorohexidine digluconate. J Microencapsul 2022; 39:110-124. [DOI: 10.1080/02652048.2022.2050318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Pratibha G. Kakadia
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield, UK
| | - Barbara R. Conway
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield, UK
- Institute of Skin Integrity and Infection Prevention, University of Huddersfield, Huddersfield, UK
| |
Collapse
|
12
|
Abstract
This study aimed to systematically review the literature about the virucidal efficacy of CHX in comparison to other substances used in the oral cavity. Electronic searches were performed in four databases (PubMed, Scopus, Embase, and Web of Science). Only studies that presented the following characteristics were included: (1) verified virucidal efficacy of CHX against Herpes Simplex Type-1 (HSV-1), any Influenza, or any human coronavirus (HcoV); and (2) compared the virucidal efficacy of CHX with essential oils (Listerine®), quaternary ammonium compounds, povidone-iodine, hydrogen peroxide, negative control substance, and absence of therapy. Two researchers independently selected the studies, extracted data and evaluated the risk of bias. A narrative data synthesis was used. Twenty-five studies were included, of which 21 were in vitro and four were randomized clinical trials (RCT). Studies assessed the virucidal efficacy of CHX against Herpes Simplex Type-1 (HSV-1) (10 studies), Influenza A (InfluA) (4 studies), human coronavirus (HCoV) (4 studies) and Severe Acute Respiratory Syndrome-Related Coronavirus (SARS-CoV-2) (11 studies). Most studies demonstrated that CHX has a positive virucidal efficacy against HSV-1 and InfluA strains. However, lower efficacy was shown to InfluA strain in comparison to povidone-iodine. Lower to none virucidal efficacy of CHX is expected for HCoV and SARS-CoV-2 strains for in vitro studies. Three RCT demonstrated that CHX was able to significantly reduce the viral load of SARS-CoV-2 for a short period. CHX may present an interesting virucidal efficacy against HSV-1 and InfluA viruses. CHX also presents transient efficacy against SARS-CoV-2 when used as a mouthwash.
Collapse
|
13
|
Dockery DM, Allu S, Vishwanath N, Li T, Berns E, Glasser J, Spake CSL, Antoci V, Born CT, Garcia DR. Review of Pre-Operative Skin Preparation Options Based on Surgical Site in Orthopedic Surgery. Surg Infect (Larchmt) 2021; 22:1004-1013. [PMID: 34388024 DOI: 10.1089/sur.2021.085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Surgical site infections (SSIs) are a primary contributor to surgical morbidity and mortality, causing a substantial financial burden on the healthcare system. Specifically, Cutibacterium acnes contributes greatly to infections in the shoulder and spine regions. Prevention of infection is crucial to improve patient outcomes and reduce costs. This article reviews current surgical skin preparation solutions, the unique distribution of organisms at common orthopedic surgical sites, and recommends solutions based on surgical location. Methods: A search of electronic databases (PubMed, MEDLINE, and Embase) was conducted for relevant literature until December 2020. Sources were compiled based on title and abstract, then full texts were read for possible inclusion. This review summarizes the most recent publications in the field of SSIs and preparation solutions. Results: The mechanism and efficacy of alcohol-, iodine-, and chlorhexidine-based preparations were reviewed, along with experimental preparations. This article identifies common colonization patterns for the shoulder, elbow, hip, knee, spine, foot, and ankle, and discusses recommendations for preparations based on current evidence. Recommendations: For shoulder and elbow operations, we recommend ChloraPrep™ (CareFusion, BD, El Paso, TX), DuraPrep™ (3M Health Care, St. Paul, MN), or Betadine® applied with 4 × 4 gauze sponge, three-day pre-operative benzyl peroxide, and application of 3% hydrogen peroxide before skin preparation. For the hip and knee, we recommend application of 2% chlorhexidine gluconate (CHG) cloth the night before and morning of surgery and either DuraPrep or iodine-alcohol skin prep prior to surgery. For spine surgeries, we recommended ChloraPrep. For foot and ankle, our recommendations are: ChloraPrep or DuraPrep, submersion of foot in 70% ethanol/10% isopropyl alcohol for five minutes prior to procedure, application with a bristled brush, and a second vigorous scrub with 4 × 4 soaked gauze. Conclusions: The current surgical skin preparations have both benefits and drawbacks. We recommend that orthopedic surgeons choose a skin preparation based on surgical site and prevalence of unique skin flora there.
Collapse
Affiliation(s)
- Dominique M Dockery
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Sai Allu
- Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA.,Brown University, Providence, Rhode Island, USA
| | - Neel Vishwanath
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Troy Li
- Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA.,Brown University, Providence, Rhode Island, USA
| | - Ellis Berns
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Jillian Glasser
- Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Carole S L Spake
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Valentin Antoci
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA.,Brown University, Providence, Rhode Island, USA.,Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Christopher T Born
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA.,Brown University, Providence, Rhode Island, USA.,Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Dioscaris R Garcia
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA.,Brown University, Providence, Rhode Island, USA.,Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| |
Collapse
|
14
|
Dramowski A, Pillay S, Bekker A, Abrahams I, Cotton MF, Coffin SE, Whitelaw AC. Impact of 1% chlorhexidine gluconate bathing and emollient application on bacterial pathogen colonization dynamics in hospitalized preterm neonates - A pilot clinical trial. EClinicalMedicine 2021; 37:100946. [PMID: 34195575 PMCID: PMC8225683 DOI: 10.1016/j.eclinm.2021.100946] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 05/14/2021] [Accepted: 05/18/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Chlorhexidine gluconate (CHG) body washes and emollient application may modulate bacterial pathogen colonization and prevent neonatal hospital-acquired infections. METHODS This pilot, non-randomized, open-label trial, enrolled preterm neonates (1000-1500g; day 1-3 of life) at a tertiary hospital in Cape Town, South Africa. Participants were sequentially allocated to 4 trial arms (n=20 each): 1% aqueous CHG (CHG), 1% CHG plus emollient (CHG+EM), emollient only (EM) and standard of care (SOC: no antiseptic/emollient). Trial treatment/s were applied daily for 10 days (d) post-enrolment, documenting neonatal skin condition score. Anterior nose, neck, umbilical and perianal swabs for bacterial culture were collected at d1, d3, d10 and d16 post-enrolment, (±1 day), reporting pathogen acquisition rates and semi-quantitative bacterial colony counts. (ClinicalTrials.gov identifier: NCT03896893; trial status: closed). FINDINGS Eighty preterm neonates (mean gestational age 30 weeks [SD 2]) were enrolled between 4 March and 26 August 2019. The bacterial pathogen acquisition rate (comparing d1 and d16 swabs) varied from 33·9% [95%CI 22·9-47·0] at the umbilicus, 39·3% [95%CI 27·6-52·4] at the neck, to 71·4% [95%CI 58·5-81·7] at both the nose and perianal region. At d10, CHG babies had reduced bacterial density detected from neck, umbilicus, and perianal swabs compared to other groups (see Table 3). Following intervention cessation, colonization density was similar across all trial arms, but S. aureus colonization was more prevalent among EM and CHG+EM babies. Neonatal skin condition score improved in babies receiving emollient application (EM: -0·87 [95%CI 0·69-1·06] and CHG+EM: -0·73 [0·45-0·99]), compared to the SOC and CHG arms (Table 2); no CHG-related skin reactions occurred. INTERPRETATION Bacterial colonization density was significantly reduced in babies receiving 1% CHG washes but colonization levels rebounded rapidly post-intervention. Emollient application improved skin condition but was associated with higher rates of S. aureus colonization. FUNDING South African Medical Research Council; National Institutes of Health (TW010682).
Collapse
Key Words
- ACC, aerobic colony count
- AE, adverse event
- AMR, antimicrobial resistance
- ART, antiretroviral therapy
- BSI, bloodstream infection
- CFU, colony forming unit
- CHG, chlorhexidine gluconate
- CI, confidence interval
- EM, emollient
- ESBL, extended-spectrum B-lactamase
- HAI, healthcare-associated infection
- HIV, human immunodeficiency virus
- IPC, infection prevention and control
- KMC, kangaroo mother care
- LMIC, low-to-middle income countries
- NEC, necrotizing enterocolitis
- NICU, neonatal intensive care unit
- SD, standard deviation
- SOC, standard of care
- UIPC, Unit for Infection Prevention and Control
- UTI, urinary tract infection
- VLBW, very low birth weight
- bacterial colonization
- chlorhexidine gluconate
- d, day
- emollient
- hospital-acquired infection
- infection prevention
- nCPAP, nasal cannula positive airways pressure
- neonatal unit
- spp, species
Collapse
Affiliation(s)
- Angela Dramowski
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town 8000, South Africa
- Corresponding author.
| | - Sheylyn Pillay
- Division of Medical Microbiology, Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University and National Health Laboratory Service, Tygerberg Hospital, Cape Town, South Africa
| | - Adrie Bekker
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town 8000, South Africa
| | - Ilhaam Abrahams
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town 8000, South Africa
| | - Mark F. Cotton
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town 8000, South Africa
| | - Susan E. Coffin
- Division of Infectious Diseases, Children's Hospital of Philadelphia and Department of Paediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, USA
| | - Andrew C. Whitelaw
- Division of Medical Microbiology, Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University and National Health Laboratory Service, Tygerberg Hospital, Cape Town, South Africa
| |
Collapse
|
15
|
Integrated genomic, epidemiologic investigation of Candida auris skin colonization in a skilled nursing facility. Nat Med 2021; 27:1401-1409. [PMID: 34155414 DOI: 10.1038/s41591-021-01383-w] [Citation(s) in RCA: 78] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 05/05/2021] [Indexed: 02/06/2023]
Abstract
Candida auris is a fungal pathogen of high concern due to its ability to cause healthcare-associated infections and outbreaks, its resistance to antimicrobials and disinfectants and its persistence on human skin and in the inanimate environment. To inform surveillance and future mitigation strategies, we defined the extent of skin colonization and explored the microbiome associated with C. auris colonization. We collected swab specimens and clinical data at three times points between January and April 2019 from 57 residents (up to ten body sites each) of a ventilator-capable skilled nursing facility with endemic C. auris and routine chlorhexidine gluconate (CHG) bathing. Integrating microbial-genomic and epidemiologic data revealed occult C. auris colonization of multiple body sites not targeted commonly for screening. High concentrations of CHG were associated with suppression of C. auris growth but not with deleterious perturbation of commensal microbes. Modeling human mycobiome dynamics provided insight into underlying alterations to the skin fungal community as a possible modifiable risk factor for acquisition and persistence of C. auris. Failure to detect the extensive, disparate niches of C. auris colonization may reduce the effectiveness of infection-prevention measures that target colonized residents, highlighting the importance of universal strategies to reduce C. auris transmission.
Collapse
|
16
|
Popovich KJ, Green SJ, Okamoto K, Rhee Y, Hayden MK, Schoeny M, Snitkin ES, Weinstein RA. MRSA Transmission in Intensive Care Units: Genomic Analysis of Patients, Their Environments, and Healthcare Workers. Clin Infect Dis 2021; 72:1879-1887. [PMID: 32505135 PMCID: PMC8315036 DOI: 10.1093/cid/ciaa731] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 06/03/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Methicillin-resistant Staphylococcus aureus (MRSA)-and now USA300 MRSA-is a significant intensive care unit (ICU) pathogen; healthcare worker (HCW) contamination may lead to patient cross-transmission. METHODS From September 2015 to February 2016, to study the spread of MRSA, we enrolled HCWs in 4 adult ICUs caring for patients on MRSA contact precautions. Samples were collected from patient body sites and high-touch surfaces in patient rooms. HCW hands, gloves, and personal protective equipment were sampled pre/post-patient encounter. Whole genome sequencing (WGS) was used to compare isolates from patients, HCWs, and environment. RESULTS There were 413 MRSA isolates sequenced (38% USA300, 52% USA100) from 66 patient encounters. Six of 66 HCWs were contaminated with MRSA prior to room entry. Isolates from a single patient encounter were typically either USA100 or USA300; in 8 (12%) encounters both USA300 and USA100 were isolated. WGS demonstrated that isolates from patients, HCWs, and environment often were genetically similar, although there was substantial between-encounter diversity. Strikingly, there were 5 USA100 and 1 USA300 clusters that contained similar strains (<22 single-nucleotide variants [SNVs], with most <10 SNVs) within the cluster despite coming from different encounters, suggesting intra- and inter-ICU spread of strains, that is, 4 of these genomic clusters were from encounters in the same ICU; 5 of 6 clusters occurred within 1 week. CONCLUSIONS We demonstrated frequent spread of MRSA USA300 and USA100 strains among patients, environment, and HCWs. WGS identified possible spread within and even between ICUs. Future analysis with detailed contact tracing in conjunction with genomic data may further elucidate pathways of MRSA spread and points for intervention.
Collapse
Affiliation(s)
- Kyle J Popovich
- Division of Infectious Disease, Rush University Medical Center/Cook County Health, Chicago, Illinois, USA
| | - Stefan J Green
- Genome Research Core, Research Resources Center, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Koh Okamoto
- Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan
| | - Yoona Rhee
- Division of Infectious Disease, Rush University Medical Center/Cook County Health, Chicago, Illinois, USA
| | - Mary K Hayden
- Division of Infectious Disease, Rush University Medical Center, Chicago, Illinois, USA
| | - Michael Schoeny
- Community, Systems, and Mental Health Nursing Rush University Medical Center, Chicago, Illinois, USA
| | - Evan S Snitkin
- Department of Microbiology and Immunology and Division of Infectious Disease, Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Robert A Weinstein
- Division of Infectious Disease, Rush University Medical Center/Cook County Health, Chicago, Illinois, USA
| |
Collapse
|
17
|
Knobloch MJ, Musuuza JS, McKinley L, Zimbric ML, Baubie K, Hundt AS, Carayon P, Hagle M, Pfeiffer CD, Galea MD, Crnich CJ, Safdar N. Implementing daily chlorhexidine gluconate (CHG) bathing in VA settings: The human factors engineering to prevent resistant organisms (HERO) project. Am J Infect Control 2021; 49:775-783. [PMID: 33359552 DOI: 10.1016/j.ajic.2020.12.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 12/12/2020] [Accepted: 12/21/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Daily use of chlorhexidine gluconate (CHG) has been shown to reduce risk of healthcare-associated infections. We aimed to assess moving CHG bathing into routine practice using a human factors approach. We evaluated implementation in non-intensive care unit (ICU) settings in the Veterans Health Administration. METHODS Our multiple case study approach included non-ICU units from 4 Veterans Health Administration settings. Guided by the Systems Engineering Initiative for Patient Safety, we conducted focus groups and interviews to capture barriers and facilitators to daily CHG bathing. We measured compliance using observations and skin CHG concentrations. RESULTS Barriers to daily CHG include time, concern of increasing antibiotic resistance, workflow and product concerns. Facilitators include engagement of champions and unit shared responsibility. We found shortfalls in patient education, hand hygiene and CHG use on tubes and drains. CHG skin concentration levels were highest among patients from spinal cord injury units. These units applied antiseptic using 2% CHG impregnated wipes vs 4% CHG solution/soap. DISCUSSION Non-ICUs implementing CHG bathing must consider human factors and work system barriers to ensure uptake and sustained practice change. CONCLUSIONS Well-planned rollouts and a unit culture promoting shared responsibility are key to compliance with daily CHG bathing. Successful implementation requires attention to staff education and measurement of compliance.
Collapse
|
18
|
Reynolds SS, Woltz P, Keating E, Neff J, Elliott J, Hatch D, Yang Q, Granger BB. Results of the CHlorhexidine Gluconate Bathing implementation intervention to improve evidence-based nursing practices for prevention of central line associated bloodstream infections Study (CHanGing BathS): a stepped wedge cluster randomized trial. Implement Sci 2021; 16:45. [PMID: 33902653 PMCID: PMC8074470 DOI: 10.1186/s13012-021-01112-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 04/07/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Central line-associated bloodstream infections (CLABSIs) result in approximately 28,000 deaths and approximately $2.3 billion in added costs to the U.S. healthcare system each year, and yet, many of these infections are preventable. At two large health systems in the southeast United States, CLABSIs continue to be an area of opportunity. Despite strong evidence for interventions to prevent CLABSI and reduce associated patient harm, such as use of chlorhexidine gluconate (CHG) bathing, the adoption of these interventions in practice is poor. The primary objective of this study was to assess the effect of a tailored, multifaceted implementation program on nursing staff's compliance with the CHG bathing process and electronic health record (EHR) documentation in critically ill patients. The secondary objectives were to examine the (1) moderating effect of unit characteristics and cultural context, (2) intervention effect on nursing staff's knowledge and perceptions of CHG bathing, and (3) intervention effect on CLABSI rates. METHODS A stepped wedged cluster-randomized design was used with units clustered into 4 sequences; each sequence consecutively began the intervention over the course of 4 months. The Grol and Wensing Model of Implementation helped guide selection of the implementation strategies, which included educational outreach visits and audit and feedback. Compliance with the appropriate CHG bathing process and daily CHG bathing documentation were assessed. Outcomes were assessed 12 months after the intervention to assess for sustainability. RESULTS Among the 14 clinical units participating, 8 were in a university hospital setting and 6 were in community hospital settings. CHG bathing process compliance and nursing staff's knowledge and perceptions of CHG bathing significantly improved after the intervention (p = .009, p = .002, and p = .01, respectively). CHG bathing documentation compliance and CLABSI rates did not significantly improve; however, there was a clinically significant 27.4% decrease in CLABSI rates. CONCLUSIONS Using educational outreach visits and audit and feedback implementation strategies can improve adoption of evidence-based CHG bathing practices. TRIAL REGISTRATION ClinicalTrials.gov, NCT03898115 , Registered 28 March 2019.
Collapse
Affiliation(s)
- Staci S Reynolds
- Duke University School of Nursing, 307 Trent Drive, Durham, NC, 27710, USA.
- Duke University Hospital, 2310 Erwin Road, Durham, NC, 27710, USA.
| | - Patricia Woltz
- WakeMed Health & Hospitals, 3000 New Bern Avenue, Raleigh, NC, 27610, USA
| | - Edward Keating
- Duke University Hospital, 2310 Erwin Road, Durham, NC, 27710, USA
| | - Janice Neff
- WakeMed Health & Hospitals, 3000 New Bern Avenue, Raleigh, NC, 27610, USA
| | - Jennifer Elliott
- WakeMed Health & Hospitals, 3000 New Bern Avenue, Raleigh, NC, 27610, USA
| | - Daniel Hatch
- Duke University School of Nursing, 307 Trent Drive, Durham, NC, 27710, USA
| | - Qing Yang
- Duke University School of Nursing, 307 Trent Drive, Durham, NC, 27710, USA
| | - Bradi B Granger
- Duke University School of Nursing, 307 Trent Drive, Durham, NC, 27710, USA
- Duke University Health System, 2310 Erwin Road, Durham, NC, 27710, USA
| |
Collapse
|
19
|
Shen J, McFarland AG, Young VB, Hayden MK, Hartmann EM. Toward Accurate and Robust Environmental Surveillance Using Metagenomics. Front Genet 2021; 12:600111. [PMID: 33747038 PMCID: PMC7973286 DOI: 10.3389/fgene.2021.600111] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 01/21/2021] [Indexed: 01/23/2023] Open
Abstract
Environmental surveillance is a critical tool for combatting public health threats represented by the global COVID-19 pandemic and the continuous increase of antibiotic resistance in pathogens. With its power to detect entire microbial communities, metagenomics-based methods stand out in addressing the need. However, several hurdles remain to be overcome in order to generate actionable interpretations from metagenomic sequencing data for infection prevention. Conceptually and technically, we focus on viability assessment, taxonomic resolution, and quantitative metagenomics, and discuss their current advancements, necessary precautions and directions to further development. We highlight the importance of building solid conceptual frameworks and identifying rational limits to facilitate the application of techniques. We also propose the usage of internal standards as a promising approach to overcome analytical bottlenecks introduced by low biomass samples and the inherent lack of quantitation in metagenomics. Taken together, we hope this perspective will contribute to bringing accurate and consistent metagenomics-based environmental surveillance to the ground.
Collapse
Affiliation(s)
- Jiaxian Shen
- Department of Civil and Environmental Engineering, Northwestern University, Evanston, IL, United States
| | - Alexander G. McFarland
- Department of Civil and Environmental Engineering, Northwestern University, Evanston, IL, United States
| | - Vincent B. Young
- Division of Infectious Diseases, Department of Internal Medicine, The University of Michigan Medical School, Ann Arbor, MI, United States
| | - Mary K. Hayden
- Division of Infectious Diseases, Department of Internal Medicine, Rush University Medical Center, Chicago, IL, United States
| | - Erica M. Hartmann
- Department of Civil and Environmental Engineering, Northwestern University, Evanston, IL, United States
| |
Collapse
|
20
|
Babiker A, Lutgring JD, Fridkin S, Hayden MK. Assessing the Potential for Unintended Microbial Consequences of Routine Chlorhexidine Bathing for Prevention of Healthcare-associated Infections. Clin Infect Dis 2021; 72:891-898. [PMID: 32766819 PMCID: PMC8432606 DOI: 10.1093/cid/ciaa1103] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 07/28/2020] [Indexed: 11/13/2022] Open
Abstract
Chlorhexidine gluconate (CHG) is an antiseptic that is widely used in healthcare due to its excellent safety profile and wide spectrum of activity. Daily bathing with CHG has proven to be effective in the prevention of healthcare-associated infections and multidrug-resistant pathogen decolonization. Despite the proven benefits of CHG use, there remain concerns and unanswered questions about the potential for unintended microbial consequences of routine CHG bathing. This review aims to explore some of these questions.
Collapse
Affiliation(s)
- Ahmed Babiker
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Joseph D Lutgring
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Scott Fridkin
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Mary K Hayden
- Department of Internal Medicine (Infectious Diseases), Rush University Medical Center, Chicago, Illinois, USA
- Department of Pathology, Rush University Medical Center, Chicago, Illinois, USA
| |
Collapse
|
21
|
Salazar-Vargas K, Padilla-Orozco M, Garza-González E, Camacho-Ortiz A. Chlorhexidine impregnated surgical scrubs and whole-body wash for reducing colonization of health care personnel. Am J Infect Control 2020; 48:1216-1219. [PMID: 32057510 DOI: 10.1016/j.ajic.2020.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 01/07/2020] [Accepted: 01/08/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND The use of chlorhexidine as a strategy to reduce nosocomial infections in patients has been proven useful. Bacterial contamination of health care worker's uniforms during routine patient care has been demonstrated to have potential for horizontal transmission of pathogens. METHODS We performed a prospective, open comparative trial. We included nurses who were in direct patient care and evaluated clothing microbial growth during 3 interventions: (1) participants were given a sterile surgical scrub (SSS) to put on the beginning of the shift, (2) they were instructed to take a chlorhexidine bath (CHG-B) before putting on the SSS, and (3) participants were given a chlorhexidine impregnated SSS (CI-SSS). Cultures were obtained from 3 areas (chest pocket, chest, and abdominal) at hour 0, 6, and 12 hours after the start of the shift. RESULTS A total of 306 cultures processed with 17 bacterial groups. The uniform area with the highest number of CFU was the abdomen (818 CFU), followed by the thorax (654 CFU). Over 50% of the bacterial load occurred at 12 hours (1,092 CFU at 12 hours, 766 CFU at 6 hours, and 184 CFU at 0 hour). There was a significant reduction in CFU when SSS was compared to CHG-B (CFU mean = 12.5 [0-118] vs CFU mean = 3.5 [0-22], P = .003); and SSS versus CI-SSS (CFU mean = 12.5 [0-118] vs CFU mean = 3 [0-39], P = .007). No severe adverse events were reported. CONCLUSIONS Bacterial load in uniforms decreased when chlorhexidine was used (bathing of personnel or impregnation) when compared to the use of a sterile uniform.
Collapse
Affiliation(s)
- Karina Salazar-Vargas
- Department of Internal Medicine, Hospital Universitario Dr. José Eleuterio González, Facultad de Medicina, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - Magaly Padilla-Orozco
- Department of Hospital Epidemiology and Infectious Disease Service, Hospital Universitario Dr. José Eleuterio González, Facultad de Medicina, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - Elvira Garza-González
- Gastroenterology service, Hospital Universitario Dr. José Eleuterio González, Facultad de Medicina, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - Adrián Camacho-Ortiz
- Department of Hospital Epidemiology and Infectious Disease Service, Hospital Universitario Dr. José Eleuterio González, Facultad de Medicina, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México.
| |
Collapse
|
22
|
Impact of preoperative chlorhexidine gluconate (CHG) application methods on preoperative CHG skin concentration. Infect Control Hosp Epidemiol 2020; 42:464-466. [PMID: 32993846 DOI: 10.1017/ice.2020.448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Elective surgical patients routinely bathe with chlorhexidine gluconate (CHG) at home days prior to their procedures. However, the impact of home CHG bathing on surgical site CHG concentration is unclear. We examined 3 different methods of applying CHG and hypothesized that different application methods would impact resulting CHG skin concentration.
Collapse
|
23
|
Park KH, Jung M, Kim DY, Lee YM, Lee MS, Ryu BH, Hong SI, Hong KW, Bae IG, Cho OH. Effects of subinhibitory concentrations of chlorhexidine and mupirocin on biofilm formation in clinical meticillin-resistant Staphylococcus aureus. J Hosp Infect 2020; 106:295-302. [PMID: 32679053 DOI: 10.1016/j.jhin.2020.07.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 07/06/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The effects of subinhibitory concentrations (sub-MICs) of antibacterial agents on the biofilm-forming ability of Staphylococcus aureus require further study. AIM To investigate the effects of sub-MICs of chlorhexidine and mupirocin on biofilm formation in clinical meticillin-resistant Staphylococcus aureus (MRSA) isolates. METHODS MRSA isolates were collected from patients with bloodstream infections at a tertiary care hospital. The basal level of biofilm formation and biofilm induction by sub-MICs of chlorhexidine and mupirocin were evaluated by measuring biofilm mass stained with Crystal Violet. FINDINGS Of the 112 MRSA isolates tested, 63 (56.3%) and 44 (39.3%) belonged to sequence type (ST)5 and ST72 lineages, respectively, which are the predominant healthcare- and community-associated clones in South Korea. ST5 isolates were more likely to have chlorhexidine MIC ≥4 (73.0% vs 29.5%), resistance to mupirocin (23.8% vs 0%), agr dysfunction (73.0% vs 9.1%), and qacA/B gene (58.7% vs 2.3%) compared to ST72 isolates. The basal level of biofilm formation ability was frequently stronger in ST72 isolates compared to ST5 isolates (77.3% vs 12.7%). Sub-MICs of chlorhexidine and mupirocin promoted biofilm formation in 56.3% and 53.6%, respectively, of all isolates. Biofilm induction was more prevalent in ST5 isolates (85.7% for chlorhexidine, 69.8% for mupirocin) than in ST72 isolates (15.9% for chlorhexidine, 27.3% for mupirocin). CONCLUSION Sub-MICs of chlorhexidine and mupirocin promoted biofilm formation in half of the clinical MRSA isolates. Our results suggest that ST5 MRSA biofilm can be induced together with some other bacterial virulent factors following exposure to chlorhexidine, which might confer a survival advantage to this clone in the healthcare environment.
Collapse
Affiliation(s)
- K-H Park
- Division of Infectious Diseases, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University School of Medicine, Seoul, Republic of Korea
| | - M Jung
- Division of Infectious Diseases, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University School of Medicine, Seoul, Republic of Korea
| | - D Y Kim
- Division of Infectious Diseases, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University School of Medicine, Seoul, Republic of Korea
| | - Y-M Lee
- Division of Infectious Diseases, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University School of Medicine, Seoul, Republic of Korea
| | - M S Lee
- Division of Infectious Diseases, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University School of Medicine, Seoul, Republic of Korea
| | - B-H Ryu
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Gyeongsang National University College of Medicine, Changwon, Republic of Korea
| | - S I Hong
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Gyeongsang National University College of Medicine, Changwon, Republic of Korea
| | - K-W Hong
- Department of Internal Medicine, Gyeongsang National University Hospital, Gyeongsang National University College of Medicine, Jinju, Republic of Korea
| | - I-G Bae
- Department of Internal Medicine, Gyeongsang National University Hospital, Gyeongsang National University College of Medicine, Jinju, Republic of Korea; Gyeongsang Institute of Health Sciences, Gyeongsang National University College of Medicine, Jinju, Republic of Korea
| | - O-H Cho
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Gyeongsang National University College of Medicine, Changwon, Republic of Korea; Gyeongsang Institute of Health Sciences, Gyeongsang National University College of Medicine, Jinju, Republic of Korea.
| |
Collapse
|
24
|
Stone R, Jockheck-Clark AR, Natesan S, Rizzo JA, Wienandt NA, Scott LL, Larson DA, Wall JT, Holik MA, Shaffer LJ, Park N, Jovanovic A, Tetens S, Roche ED, Shi L, Christy RJ. Enzymatic Debridement of Porcine Burn Wounds via a Novel Protease, SN514. J Burn Care Res 2020; 41:1015-1028. [PMID: 32615590 DOI: 10.1093/jbcr/iraa111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Necrotic tissue generated by a thermal injury is typically removed via surgical debridement. However, this procedure is commonly associated with blood loss and the removal of viable healthy tissue. For some patients and contexts such as extended care on the battlefield, it would be preferable to remove devitalized tissue with a nonsurgical debridement agent. In this paper, a proprietary debridement gel (SN514) was evaluated for the ability to debride both deep-partial thickness (DPT) and full-thickness burn wounds using an established porcine thermal injury model. Burn wounds were treated daily for 4 days and visualized with both digital imaging and laser speckle imaging. Strip biopsies were taken at the end of the procedure. Histological analyses confirmed a greater debridement of the porcine burn wounds by SN514 than the vehicle-treated controls. Laser speckle imaging detected significant increases in the perfusion status after 4 days of SN514 treatment on DPT wounds. Importantly, histological analyses and clinical observations suggest that SN514 gel treatment did not damage uninjured tissue as no edema, erythema, or inflammation was observed on intact skin surrounding the treated wounds. A blinded evaluation of the digital images by a burn surgeon indicated that SN514 debrided more necrotic tissue than the control groups after 1, 2, and 3 days of treatment. Additionally, SN514 gel was evaluated using an in vitro burn model that used human discarded skin. Treatment of human burned tissue with SN514 gel resulted in greater than 80% weight reduction compared with untreated samples. Together, these data demonstrate that SN514 gel is capable of debriding necrotic tissue and suggest that SN514 gel could be a useful option for austere conditions, such as military multi-domain operations and prolonged field care scenarios.
Collapse
Affiliation(s)
- Randolph Stone
- Department of Burn and Soft Tissue Research, US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas
| | - Angela R Jockheck-Clark
- Department of Burn and Soft Tissue Research, US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas
| | - Shanmugasundaram Natesan
- Department of Burn and Soft Tissue Research, US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas
| | - Julie A Rizzo
- US Army Burn Center, US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas
| | - Nathan A Wienandt
- Comparative Pathology, US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas
| | - Laura L Scott
- Epidemiology and Biostatistics, US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas
| | - David A Larson
- Department of Burn and Soft Tissue Research, US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas
| | - John T Wall
- Department of Burn and Soft Tissue Research, US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas
| | - Michelle A Holik
- Department of Burn and Soft Tissue Research, US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas
| | - Lucy J Shaffer
- Department of Burn and Soft Tissue Research, US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas
| | - Nancy Park
- Department of Burn and Soft Tissue Research, US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas
| | - Aleksa Jovanovic
- US Army Burn Center, US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas
| | - Shannon Tetens
- Department of Biologics and Regenerative Medicine, Sam Houston, Texas
| | - Eric D Roche
- Department of Biologics and Regenerative Medicine, Sam Houston, Texas
| | - Lei Shi
- Department of Biologics and Regenerative Medicine, Sam Houston, Texas
| | - Robert J Christy
- Department of Burn and Soft Tissue Research, US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas
| |
Collapse
|
25
|
Implementing daily chlorhexidine gluconate treatment for the prevention of healthcare-associated infections in non-intensive care settings: A multiple case analysis. PLoS One 2020; 15:e0232062. [PMID: 32330165 PMCID: PMC7182260 DOI: 10.1371/journal.pone.0232062] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 04/06/2020] [Indexed: 11/25/2022] Open
Abstract
Introduction Daily bathing with chlorhexidine gluconate (CHG) in hospitalized patients reduces healthcare-associated bloodstream infections and colonization by multidrug-resistant organisms. Achieving compliance with bathing protocols is challenging. This non-intensive care unit multicenter project evaluated the impact of organizational context on implementation of CHG and assessed compliance with and healthcare workers’ perceptions of the intervention. Materials and methods This was a multiple case study based on the SEIPS (Systems Engineering Initiative for Patient Safety) model of work system and patient safety. The four sites included an adult cardiovascular unit in a community hospital, a medical-surgical unit in an academic teaching pediatric hospital, an adult medical-surgical acute care unit and an adult neuroscience acute care unit in another academic teaching hospital. Complementary data collection methods included focus groups and interviews with healthcare workers (HCWs) and leaders, and direct observations of the CHG treatment process and skin swabs. Results We collected 389 bathing observations and 110 skin swabs, conducted four focus groups with frontline workers and interviewed leaders. We found variation across cases in CHG compliance, skin swab data and implementation practices. Mean compliance with the bathing process ranged from 64% to 83%. Low detectable CHG on the skin was related to immediate rinsing of CHG from the skin. Variation in the implementation of CHG treatments was related to differences in organizational education and training practices, feedback and monitoring practices, patient education or information about CHG treatments, patient preferences and general unit patient population differences. Conclusion Organizations planning to implement CHG treatments in non-ICU settings should ensure organizational readiness and buy-in and consider delivering systematic and ongoing training. Clear and systematic implementation policies across patients and units may help reduce potential confusion about treatment practices and variation across HCWs. Patient populations and unit factors need to be carefully considered and procedures developed to manage unique challenges.
Collapse
|
26
|
Use of a simple colorimetric assay to provide monitoring and feedback on adherence to chlorhexidine bathing protocols. Am J Infect Control 2020; 48:469-470. [PMID: 31864806 DOI: 10.1016/j.ajic.2019.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 10/31/2019] [Indexed: 11/22/2022]
|
27
|
2CS-CHX T Operon Signature of Chlorhexidine Tolerance among Enterococcus faecium Isolates. Appl Environ Microbiol 2019; 85:AEM.01589-19. [PMID: 31562170 DOI: 10.1128/aem.01589-19] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Accepted: 09/20/2019] [Indexed: 11/20/2022] Open
Abstract
Chlorhexidine (CHX) is a broad-spectrum antiseptic widely used in community and clinical contexts for many years that has recently acquired higher relevance in nosocomial infection control worldwide. Despite this, CHX tolerance among Enterococcus faecium bacteria, representing one of the leading agents causing nosocomial infections, has been poorly understood. This study provides new phenotypic and molecular data for better identification of CHX-tolerant E. faecium subpopulations in community and clinical contexts. The chlorhexidine MIC (MICCHX) distribution of 106 E. faecium isolates suggested the occurrence of tolerant subpopulations in diverse sources (human, animal, food, environment) and phylogenomic backgrounds (clades A1/A2/B), with predominance in clade A1. They carried a specific variant of the 2CS-CHXT operon, identified here. It encodes glucose and amino acid-polyamine-organocation family transporters, besides the DNA-binding response regulator ChtR, with a P102H mutation previously described only in CHX-tolerant clade A1 E. faecium, and the ChtS sensor. 2CS-CHXT seems to be associated with three regulons modulating diverse bacterial biological functions. Combined data from normal MIC distribution and 2CS-CHXT operon characterization support a tentative epidemiological cutoff (ECOFF) of 8 mg/liter to CHX, which is useful to detect tolerant E. faecium populations in future surveillance studies. The spread of tolerant E. faecium in diverse epidemiological backgrounds calls for the prudent use of CHX in multiple contexts.IMPORTANCE Chlorhexidine is one of the substances included in the World Health Organization's list of essential medicines, which comprises the safest and most effective medicines needed in global health systems. Although it has been widely applied as a disinfectant and antiseptic in health care (skin, hands, mouthwashes, eye drops) since the 1950s, its use in hospitals to prevent nosocomial infections has increased worldwide in recent years. Here, we provide a comprehensive study on chlorhexidine tolerance among strains of Enterococcus faecium, one of the leading nosocomial agents worldwide, and identify a novel 2CS-CHXT operon as a signature of tolerant strains occurring in diverse phylogenomic groups. Our data allowed for the proposal of a tentative epidemiological cutoff of 8 mg/liter, which is useful to detect tolerant E. faecium populations in surveillance studies in community and clinical contexts. The prediction of 2CS-CHXT regulons will also facilitate the design of future experimental studies to better uncover chlorhexidine tolerance among E. faecium bacteria.
Collapse
|
28
|
Association between chlorhexidine gluconate concentrations and resistant bacterial bioburden on skin. Infect Control Hosp Epidemiol 2019; 40:1430-1432. [PMID: 31601280 DOI: 10.1017/ice.2019.265] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
We studied the association between chlorhexidine gluconate (CHG) concentration on skin and resistant bacterial bioburden. CHG was almost always detected on the skin, and detection of methicillin-resistant Staphylococcus aureus, carbapenem-resistant Enterobacteriaceae, and vancomycin-resistant Enterococcus on skin sites was infrequent. However, we found no correlation between CHG concentration and bacterial bioburden.
Collapse
|
29
|
Huang SS. Chlorhexidine-based decolonization to reduce healthcare-associated infections and multidrug-resistant organisms (MDROs): who, what, where, when, and why? J Hosp Infect 2019; 103:235-243. [PMID: 31494130 DOI: 10.1016/j.jhin.2019.08.025] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 08/29/2019] [Indexed: 10/26/2022]
Abstract
Body surface decolonization with chlorhexidine bathing and nasal mupirocin has become a simple solution for prevention of healthcare-associated infections. The clinical trial evidence for this practice will be reviewed to understand who benefits from this practice, for what reasons, and at what times. The method of bathing and nasal decolonization will also be discussed as proper application is needed for maximal effectiveness. Finally, the conflict between current effectiveness and future potential for fueling resistance is considered.
Collapse
Affiliation(s)
- S S Huang
- Division of Infectious Diseases and Health Policy Research Institute, University of California Irvine School of Medicine, Irvine, California, USA.
| |
Collapse
|
30
|
Carbapenem-resistant Klebsiella pneumoniae with low chlorhexidine susceptibility. THE LANCET. INFECTIOUS DISEASES 2019; 19:932-933. [DOI: 10.1016/s1473-3099(19)30427-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 07/18/2019] [Indexed: 11/20/2022]
|
31
|
Kates AE, Zimbric ML, Mitchell K, Skarlupka J, Safdar N. The impact of chlorhexidine gluconate on the skin microbiota of children and adults: A pilot study. Am J Infect Control 2019; 47:1014-1016. [PMID: 30879799 DOI: 10.1016/j.ajic.2019.01.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 01/28/2019] [Accepted: 01/28/2019] [Indexed: 11/30/2022]
Abstract
We examined the effect of chlorhexidine gluconate (CHG) bathing on the skin microbiota of adult and pediatric patients. We observed no differences in pediatric patients; however, multiple genera of bacteria were observed to be significantly less abundant in the adults bathing with CHG. Further research is needed to determine the long-term impact of CHG use on the skin microbiota.
Collapse
Affiliation(s)
- Ashley E Kates
- Division of Infectious Disease, University of Wisconsin School of Medicine & Public Health, Madison, WI; Department of Medicine, William S. Middleton Memorial Veterans Hospital, Madison, WI.
| | - Michele L Zimbric
- Division of Infectious Disease, University of Wisconsin School of Medicine & Public Health, Madison, WI; Department of Medicine, William S. Middleton Memorial Veterans Hospital, Madison, WI
| | - Kaitlin Mitchell
- Division of Infectious Disease, University of Wisconsin School of Medicine & Public Health, Madison, WI
| | - Joseph Skarlupka
- Division of Infectious Disease, University of Wisconsin School of Medicine & Public Health, Madison, WI; Department of Medicine, William S. Middleton Memorial Veterans Hospital, Madison, WI
| | - Nasia Safdar
- Division of Infectious Disease, University of Wisconsin School of Medicine & Public Health, Madison, WI; Department of Medicine, William S. Middleton Memorial Veterans Hospital, Madison, WI
| |
Collapse
|
32
|
Bashir M, Hollingsworth A, Schwab D, Prinsen K, Paulson J, Morse D, Bernatchez S. Ex vivo and in vivo evaluation of residual chlorhexidine gluconate on skin following repetitive exposure to saline and wiping with 2% chlorhexidine gluconate/70% isopropyl alcohol pre-operative skin preparations. J Hosp Infect 2019; 102:256-261. [DOI: 10.1016/j.jhin.2018.10.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 10/08/2018] [Indexed: 11/26/2022]
|
33
|
Baier C, Ipaktchi R, Schwab F, Smith A, Liu X, Ebadi E, Limbourg A, Mett TR, Bange FC, Vogt PM. Universal decolonization with octenidine: First experiences in a tertiary burn intensive care unit. BURNS OPEN 2019. [DOI: 10.1016/j.burnso.2018.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
|
34
|
Johnson J, Suwantarat N, Colantuoni E, Ross TL, Aucott SW, Carroll KC, Milstone AM. The impact of chlorhexidine gluconate bathing on skin bacterial burden of neonates admitted to the Neonatal Intensive Care Unit. J Perinatol 2019; 39:63-71. [PMID: 30237474 PMCID: PMC6298801 DOI: 10.1038/s41372-018-0231-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 07/23/2018] [Accepted: 08/21/2018] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To assess the impact of chlorhexidine gluconate (CHG) bathing on skin bacterial burden in neonates. STUDY DESIGN In this prospective observational study, arm and groin skin bacterial growth was measured in 40 CHG-exposed and nonexposed neonates admitted to the NICU. Exposed neonates received 2% CHG baths per protocol for central line-associated bloodstream infection (CLABSI) prevention or Staphylococcus aureus decolonization. RESULTS Forty neonates were enrolled, 18 of whom were CHG-exposed. Mean baseline Gram-positive (GP) bacterial burden was 2.19 log CFU/ml on the arm and 1.81 log CFU/ml on the groin. Bacterial burden decreased after the first bath, but returned to baseline by 72 h. Residual skin CHG concentration declined over time, with a corresponding increase in GP bacterial burden. CONCLUSIONS CHG bathing reduces skin bacterial burden, but burden returns to baseline after 72 h. Twice weekly CHG bathing may be inadequate to suppress skin bacterial growth in hospitalized neonates.
Collapse
Affiliation(s)
- Julia Johnson
- Department of Pediatrics, Division of Neonatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Nuntra Suwantarat
- Department of Pathology, Division of Medical Microbiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Elizabeth Colantuoni
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Maryland, United States of America
| | - Tracy L. Ross
- Department of Pathology, Division of Medical Microbiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Susan W. Aucott
- Department of Pediatrics, Division of Neonatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Karen C. Carroll
- Department of Pathology, Division of Medical Microbiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Aaron M. Milstone
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Johns Hopkins University School of Medicine, Maryland, United States of America
| |
Collapse
|
35
|
EfrEF and the Transcription Regulator ChlR Are Required for Chlorhexidine Stress Response in Enterococcus faecalis V583. Antimicrob Agents Chemother 2018; 62:AAC.00267-18. [PMID: 29610200 PMCID: PMC5971576 DOI: 10.1128/aac.00267-18] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 03/16/2018] [Indexed: 12/28/2022] Open
Abstract
Enterococcus faecalis is an opportunistic pathogen and leading cause of health care-associated infections. Daily chlorhexidine gluconate (CHG) bathing of patients is generally regarded as an effective strategy to reduce the occurrence of health care-associated infections. It is likely that E. faecalis is frequently exposed to inhibitory and subinhibitory concentrations of CHG in clinical settings. The goal of this study was to investigate how the vancomycin-resistant strain E. faecalis V583 transcriptionally responds to and tolerates stress from CHG. We used transcriptome (microarray) analysis to identify genes upregulated by E. faecalis V583 in response to CHG. The genes efrE (EF2226) and efrF (EF2227), encoding a heterodimeric ABC transport system, were the most highly upregulated genes. efrEF expression was induced by CHG at concentrations several 2-fold dilutions below the MIC. Deletion of efrEF increased E. faecalis V583 susceptibility to CHG. We found that ChlR, a MerR-like regulator encoded by a sequence upstream of efrEF, mediated the CHG-dependent upregulation of efrEF, and deletion of chlR also increased chlorhexidine susceptibility. Overall, our study gives insight into E. faecalis stress responses to a commonly used antiseptic.
Collapse
|
36
|
Differential Effects of Chlorhexidine Skin Cleansing Methods on Residual Chlorhexidine Skin Concentrations and Bacterial Recovery. Infect Control Hosp Epidemiol 2018; 39:405-411. [PMID: 29493475 DOI: 10.1017/ice.2017.312] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Bathing intensive care unit (ICU) patients with 2% chlorhexidine gluconate (CHG)-impregnated cloths decreases the risk of healthcare-associated bacteremia and multidrug-resistant organism transmission. Hospitals employ different methods of CHG bathing, and few studies have evaluated whether those methods yield comparable results. OBJECTIVE To determine whether 3 different CHG skin cleansing methods yield similar residual CHG concentrations and bacterial densities on skin. DESIGN Prospective, randomized 2-center study with blinded assessment. PARTICIPANTS AND SETTING Healthcare personnel in surgical ICUs at 2 tertiary-care teaching hospitals in Chicago, Illinois, and Boston, Massachusetts, from July 2015 to January 2016. INTERVENTION Cleansing skin of one forearm with no-rinse 2% CHG-impregnated polyester cloth (method A) versus 4% CHG liquid cleansing with rinsing on the contralateral arm, applied with either non-antiseptic-impregnated cellulose/polyester cloth (method B) or cotton washcloth dampened with sterile water (method C). RESULTS In total, 63 participants (126 forearms) received method A on 1 forearm (n=63). On the contralateral forearm, 33 participants received method B and 30 participants received method C. Immediately and 6 hours after cleansing, method A yielded the highest residual CHG concentrations (2500 µg/mL and 1250 µg/mL, respectively) and lowest bacterial densities compared to methods B or C (P<.001). CONCLUSION In healthy volunteers, cleansing with 2% CHG-impregnated cloths yielded higher residual CHG concentrations and lower bacterial densities than cleansing with 4% CHG liquid applied with either of 2 different cloth types and followed by rinsing. The relevance of these differences to clinical outcomes remains to be determined. Infect Control Hosp Epidemiol 2018;39:405-411.
Collapse
|
37
|
Alserehi H, Filippell M, Emerick M, Cabunoc MK, Preas MA, Sparkes C, Johnson JK, Leekha S. Chlorhexidine gluconate bathing practices and skin concentrations in intensive care unit patients. Am J Infect Control 2018; 46:226-228. [PMID: 28993110 DOI: 10.1016/j.ajic.2017.08.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 08/17/2017] [Accepted: 08/18/2017] [Indexed: 11/29/2022]
Abstract
In this 2-phase real-world evaluation of chlorhexidine gluconate (CHG) skin concentrations in intensive care unit patients, we found lower skin CHG concentrations when rinsing with water after CHG solution bath (compared with no rinse), but no significant difference in concentrations between the use of CHG solution without rinse and preimpregnated CHG wipes. CHG concentration audits could be useful in assessing the quality of bathing practice, and CHG solution without rinsing may be an alternative to preimpregnated CHG wipes.
Collapse
Affiliation(s)
| | | | | | | | | | - Corey Sparkes
- University of Maryland School of Medicine, Baltimore, MD
| | | | - Surbhi Leekha
- University of Maryland School of Medicine, Baltimore, MD
| |
Collapse
|
38
|
Reduced Chlorhexidine and Daptomycin Susceptibility in Vancomycin-Resistant Enterococcus faecium after Serial Chlorhexidine Exposure. Antimicrob Agents Chemother 2017; 62:AAC.01235-17. [PMID: 29038276 PMCID: PMC5740357 DOI: 10.1128/aac.01235-17] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 10/10/2017] [Indexed: 12/22/2022] Open
Abstract
Vancomycin-resistant Enterococcus faecium strains (VREfm) are critical public health concerns because they are among the leading causes of hospital-acquired bloodstream infections. Chlorhexidine (CHX) is a bisbiguanide cationic antiseptic that is routinely used for patient bathing and other infection control practices. VREfm are likely frequently exposed to CHX; however, the long-term effects of CHX exposure have not been studied in enterococci. In this study, we serially exposed VREfm to increasing concentrations of CHX for a period of 21 days in two independent experimental evolution trials. Reduced CHX susceptibility emerged (4-fold shift in CHX MIC). Subpopulations with reduced daptomycin (DAP) susceptibility were detected, which were further analyzed by genome sequencing and lipidomic analysis. Across the trials, we identified adaptive changes in genes with predicted or experimentally confirmed roles in chlorhexidine susceptibility (efrE), global nutritional stress response (relA), nucleotide metabolism (cmk), phosphate acquisition (phoU), and glycolipid biosynthesis (bgsB), among others. Moreover, significant alterations in membrane phospholipids were identified for some populations with reduced DAP susceptibility. Our results are clinically significant because they identify a link between serial subinhibitory CHX exposure and reduced DAP susceptibility. In addition, the CHX-induced genetic and lipidomic changes described in this study offer new insights into the mechanisms underlying the emergence of antibiotic resistance in VREfm.
Collapse
|
39
|
Ruiz J, Ramirez P, Villarreal E, Gordon M, Saez I, Rodríguez A, Castañeda MJ, Castellanos-Ortega Á. Daily bathing strategies and cross-transmission of multidrug-resistant organisms: Impact of chlorhexidine-impregnated wipes in a multidrug-resistant gram-negative bacteria endemic intensive care unit. Am J Infect Control 2017; 45:1069-1073. [PMID: 28803661 DOI: 10.1016/j.ajic.2017.06.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 06/25/2017] [Accepted: 06/26/2017] [Indexed: 01/28/2023]
Abstract
BACKGROUND Health-care associated infections are a major cause of morbidity and mortality in critical care units. The aim of this study is to evaluate the effectiveness of chlorhexidine gluconate (CHG)-impregnated wipes in the daily bathing of patients in an intensive care unit (ICU) to prevent cross-transmission and colonization by multidrug-resistant organisms (MDROs) METHODS: Prospective cohort study with an intervention of 11 months. The intervention consisted of using CHG-impregnated wipes for the daily bathing of patients on mechanical ventilation or colonized by MDROs. Monthly trends in the number of patients colonized by MDROs and the incidence of nosocomial infections were evaluated. RESULTS A total of 1,675 patients were admitted to the unit during the intervention period, and 430 (25.7%) were bathed with chlorhexidine wipes. A significant decrease was observed in the incidence of colonization by MDROs over the months (β = -0.209; r2 = 0.549; P = .027), and in the number of patients colonized compared with the equivalent period of the previous year (22.0% vs 18.4%; P = .01). No significant decrease was observed in the incidence of nosocomial infection between the two periods (4.11% vs 4.57%; P = .355). No dermatologic problems were observed in the treated patients. CONCLUSIONS The use of CHG-impregnated wipes reduces cross-transmission and colonization by MDROs in the ICUs in an endemic situation because of multidrug-resistant Enterobacteriaceae.
Collapse
Affiliation(s)
- Jesus Ruiz
- Intensive Care Unit, Instituto de Investigación Sanitaria La Fe, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Paula Ramirez
- Intensive Care Unit, Hospital Universitario y Politécnico La Fe, Valencia, Spain.
| | - Esther Villarreal
- Intensive Care Unit, Instituto de Investigación Sanitaria La Fe, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Monica Gordon
- Intensive Care Unit, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Inmaculada Saez
- Intensive Care Unit, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Alfonso Rodríguez
- Intensive Care Unit, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | | | | |
Collapse
|
40
|
Garrido-Benedicto P, Cueto-Quintana P, Farré-Termens E, Mariné-Cabré M, Riba-Reig J, Molina-Chueca R. Efecto de la higiene diaria con clorhexidina sobre la incidencia de contaminaciones de hemocultivos en el paciente crítico. ENFERMERIA INTENSIVA 2017; 28:97-104. [DOI: 10.1016/j.enfi.2016.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 10/19/2016] [Accepted: 10/19/2016] [Indexed: 10/20/2022]
|
41
|
Reese SM, Burnet N, Smith J, Escudero H, Knepper BC, Young HL. Hospital-wide chlorhexidine gluconate bed bathing protocol: A cross-sectional study in a single hospital. Am J Infect Control 2017; 45:569-571. [PMID: 28063726 DOI: 10.1016/j.ajic.2016.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 11/14/2016] [Accepted: 11/14/2016] [Indexed: 11/18/2022]
Abstract
The objective of this study was to determine understanding of bed bathing practices over time after the implementation of a standardized bed bathing protocol. An online survey addressing bathing practices was administered preintervention and 6 and 18 months postintervention to all nurses and technicians caring for adult patients. Survey responses suggested that the intervention resulted in sustained understanding of the standardized bed bathing protocol.
Collapse
Affiliation(s)
- Sara M Reese
- Department of Patient Safety and Quality, Denver Health Medical Center, Denver, CO.
| | - Nicole Burnet
- Department of Nursing, Denver Health Medical Center, Denver, CO
| | - Jan Smith
- Department of Nursing, Denver Health Medical Center, Denver, CO
| | | | - Bryan C Knepper
- Department of Patient Safety and Quality, Denver Health Medical Center, Denver, CO
| | - Heather L Young
- Department of Patient Safety and Quality, Denver Health Medical Center, Denver, CO
| |
Collapse
|
42
|
Roghmann MC, Lydecker AD, Langenberg P, Mongodin EF, Johnson JK. Microbiological effect of mupirocin and chlorhexidine for Staphylococcus aureus decolonization in community and nursing home based adults. Diagn Microbiol Infect Dis 2017; 88:53-57. [PMID: 28215714 PMCID: PMC5655989 DOI: 10.1016/j.diagmicrobio.2017.02.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 02/01/2017] [Accepted: 02/06/2017] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To compare the presence of Staphylococcus aureus and pathogenic Gram-negative rods (GNR) in the anterior nares, posterior pharynx and three skin sites in community-based adults and nursing home-based adults before and after treatment with nasal mupirocin and topical chlorhexidine. METHODS S. aureus-colonized adults were recruited from the community (n=26) and from nursing homes (n=8). Eligible participants were cultured for S. aureus and GNR during two study visits and then received intranasal mupirocin and topical chlorhexidine for 5days, with a 2-month follow-up period. RESULTS After decolonization, we found sustained decreases of S. aureus colonization in nose, throat and skin sites over 4-8weeks in both populations. Intranasal mupirocin did not increase GNR colonization in nose or throat. Chlorhexidine did not decrease GNR colonization in skin sites. CONCLUSIONS Decolonization with mupirocin and chlorhexidine leads to a sustained effect on S. aureus colonization without affecting GNR colonization.
Collapse
Affiliation(s)
- Mary-Claire Roghmann
- Geriatrics Research Education and Clinical Center, VA Maryland Health Care System, Baltimore, MD, 21201; Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, 21201.
| | - Alison D Lydecker
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, 21201
| | - Patricia Langenberg
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, 21201
| | - Emmanuel F Mongodin
- Department of Microbiology and Immunology and Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, MD, 21201
| | - J Kristie Johnson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, 21201
| |
Collapse
|
43
|
Methicillin-Resistant Staphylococcus aureus Infections: A Comprehensive Review and a Plastic Surgeon's Approach to the Occult Sites. Plast Reconstr Surg 2017; 138:515-523. [PMID: 27465172 DOI: 10.1097/prs.0000000000002358] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Up to 20 percent of the general population is persistently colonized with Staphylococcus aureus, and 1 to 3 percent of the population is colonized with community-acquired methicillin-resistant S. aureus. Currently, the knowledge of methicillin-resistant Staphylococcus aureus carriage sites other than the nose, and their effect on surgical site infections in cosmetic surgery, is lacking. METHODS A comprehensive literature review using the PubMed database to analyze prevalence, anatomical carrier sites, current screening and decontamination protocols and guidelines, and methicillin-resistant S. aureus in cosmetic surgery was performed. The senior author's (L.R.) methicillin-resistant S. aureus infection experience and prevention protocols were also reviewed. RESULTS Nasal swabs detect only 50.5 percent of methicillin-resistant S. aureus colonization, and broad screening has noted the presence of methicillin-resistant S. aureus in the ear canal and umbilicus. Decolonization protocols within the orthopedic and cardiothoracic surgery literature have reduced rates of methicillin-resistant S. aureus surgical-site infections. There are no decolonization guidelines for plastic surgeons. Since instituting their decolonization protocol, the authors have had no cases of methicillin-resistant S. aureus infection in nearly 1000 cosmetic surgery procedures. CONCLUSIONS There are very limited, if any, Level I or II data regarding methicillin-resistant S. aureus screening and decolonization. As the sequelae of a surgical-site infection can be disastrous, expert opinions recommend that plastic surgeons vigorously address methicillin-resistant S. aureus colonization and infection. The authors have developed and recommend a simple decolonization protocol that includes treatment of the umbilicus, ear canal, and nares to limit surgical-site infection and improve surgical outcomes.
Collapse
|
44
|
Schaffzin JK, Simon K, Connelly BL, Mangano FT. Standardizing preoperative preparation to reduce surgical site infections among pediatric neurosurgical patients. J Neurosurg Pediatr 2017; 19:399-406. [PMID: 28128706 DOI: 10.3171/2016.10.peds16287] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Surgical site infections (SSIs) are costly to patients and the health care system. Pediatric neurosurgery SSI risk factors are not well defined. Intraoperative protocols have reduced, but have not eliminated, SSIs. The effect of preoperative intervention is unknown. Using quality improvement methods, a preoperative SSI prevention protocol for pediatric neurosurgical patients was implemented to assess its effect on SSI rate. METHODS Patients who underwent a scheduled neurosurgical procedure between January 2014 and December 2015 were included. Published evidence and provider consensus were used to guide preoperative protocol development. The Model for Improvement was used to test interventions. Intraoperative and postoperative management was not standardized or modified systematically. Staff, family, and overall adherence was measured as all-or-nothing. In addition, SSI rates among eligible procedures were measured before and after protocol implementation. RESULTS Within 4 months, overall protocol adherence increased from 51.3% to a sustained 85.7%. SSI rates decreased from 2.9 per 100 procedures preintervention to 0.62 infections postintervention (p = 0.003). An approximate 79% reduction in SSI risk was identified (risk ratio 0.21, 95% CI 0.08-0.56; p = 0.001). CONCLUSIONS Clinical staff and families successfully collaborated on a standardized preoperative protocol for pediatric neurosurgical patients. Standardization of the preoperative phase of care alone reduced SSI rates. Attention to the preoperative in addition to the intraoperative and postoperative phases of care may lead to further reduction in SSI rates.
Collapse
Affiliation(s)
| | | | | | - Francesco T. Mangano
- Division of Pediatric Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| |
Collapse
|
45
|
Reduction in hospital-associated methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus with daily chlorhexidine gluconate bathing for medical inpatients. Am J Infect Control 2017; 45:255-259. [PMID: 27938986 DOI: 10.1016/j.ajic.2016.09.019] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 09/03/2016] [Accepted: 09/06/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND Daily bathing with chlorhexidine gluconate (CHG) is increasingly used in intensive care units to prevent hospital-associated infections, but limited evidence exists for noncritical care settings. METHODS A prospective crossover study was conducted on 4 medical inpatient units in an urban, academic Canadian hospital from May 1, 2014-August 10, 2015. Intervention units used CHG over a 7-month period, including a 1-month wash-in phase, while control units used nonmedicated soap and water bathing. Rates of hospital-associated methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) colonization or infection were the primary end point. Hospital-associated S. aureus were investigated for CHG resistance with a qacA/B and smr polymerase chain reaction (PCR) and agar dilution. RESULTS Compliance with daily CHG bathing was 58%. Hospital-associated MRSA and VRE was decreased by 55% (5.1 vs 11.4 cases per 10,000 inpatient days, P = .04) and 36% (23.2 vs 36.0 cases per 10,000 inpatient days, P = .03), respectively, compared with control cohorts. There was no significant difference in rates of hospital-associated Clostridium difficile. Chlorhexidine resistance testing identified 1 isolate with an elevated minimum inhibitory concentration (8 µg/mL), but it was PCR negative. CONCLUSIONS This prospective pragmatic study to assess daily bathing for CHG on inpatient medical units was effective in reducing hospital-associated MRSA and VRE. A critical component of CHG bathing on medical units is sustained and appropriate application, which can be a challenge to accurately assess and needs to be considered before systematic implementation.
Collapse
|
46
|
Prävention von Infektionen, die von Gefäßkathetern ausgehen. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2017; 60:171-206. [DOI: 10.1007/s00103-016-2487-4] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
|
47
|
Popovich KJ. Another look at CHG bathing in a surgical intensive care unit. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:13. [PMID: 28164098 DOI: 10.21037/atm.2016.12.76] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Kyle J Popovich
- Rush University Medical Center, Stroger Hospital of Cook County, Chicago, Illinois, USA
| |
Collapse
|
48
|
Bathing With 2% Chlorhexidine Gluconate: Evidence and Costs Associated With Central Line-Associated Bloodstream Infections. Crit Care Nurs Q 2016; 39:42-50. [PMID: 26633158 DOI: 10.1097/cnq.0000000000000096] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
In a coordinated national effort reported by the Agency for Healthcare Research and Quality, the use of 2% chlorhexidine gluconate (CHG) has reduced the central line-associated bloodstream infection (CLABSI) rate by 40%. Conversely, a recent randomized clinical trial determined that chlorhexidine bathing did not reduce the CLABSI rate. The objectives of this study were to conduct meta-analysis and clarify the effectiveness of 2% CHG bathing by nurses on CLABSIs in adult intensive care unit patients and to determine the contributing costs attributable to CLABSIs and 2% CHG bathing. Eligible studies that included the outcome of bloodstream infection rate for central lines were considered. A rigorous systematic review protocol and software tools available from the Joanna Briggs Institute via OvidSP were used. Agency for Healthcare Research and Quality tools assisted with identifiable CHG bathing costs. Four studies were included in the meta-analysis for the outcome of primary bloodstream infections, and 2 studies narratively supported the meta-analysis. A relative risk of 0.46 with 95% confidence interval (0.34-0.63) was determined. This significant effect is seen in an overall z-score of 4.84 (P < .0001). This meta-analysis supports that 2% CHG reduces CLABSIs. The estimated cost increase of 2% CHG-impregnated cloths is $4.10 versus nonmedicated bathing cloths. The cost associated with a single CLABSI is 10 times more than the cost of using 2% CHG-impregnated cloths. Nursing provides significant influence for the prevention of CLABSIs in critical care via evidence-based best practices.
Collapse
|
49
|
Huang HP, Chen B, Wang HY, He M. The efficacy of daily chlorhexidine bathing for preventing healthcare-associated infections in adult intensive care units. Korean J Intern Med 2016; 31:1159-1170. [PMID: 27048258 PMCID: PMC5094930 DOI: 10.3904/kjim.2015.240] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 08/23/2015] [Accepted: 09/06/2015] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND/AIMS Healthcare-associated infections (HAIs) in critically ill patients with prolonged length of hospital stay and increased medical costs. The aim of this study is to assess whether daily chlorhexidine gluconate (CHG) bathing will significantly reduce the rates of HAIs in adult intensive care units (ICUs). METHODS PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials were systematically searched until December 31, 2014 to identify relevant studies. Two authors independently reviewed and extracted data from included studies. All data was analyzed by Review Manager version 5.3. RESULTS Fifteen studies including three randomized controlled trials and 12 quasi-experimental studies were available in this study. The outcomes showed that daily CHG bathing were associated with significant reduction in the rates of primary outcomes: catheter-related bloodstream infection (risk ratio [RR], 0.44; 95% confidence interval [CI], 0.32 to 0.63; p < 0.00001), catheter-associated urinary tract infection (RR, 0.68; 95% CI, 0.52 to 0.88; p = 0.004), ventilator-associated pneumonia (RR, 0.73; 95% CI, 0.57 to 0.93; p = 0.01), acquisition of methicillin-resistant Staphylococcus aureus (RR, 0.78; 95% CI, 0.68 to 0.91; p = 0.001) and vancomycin-resistant Enterococcus (RR, 0.56; 95% CI, 0.31 to 0.99; p = 0.05). CONCLUSIONS Our study suggests that the use of daily CHG bathing can significantly prevent HAIs in ICUs. However, more well-designed studies are needed to confirm these findings.
Collapse
Affiliation(s)
- Hua-ping Huang
- Nursing Administration, Mianyang Central Hospital, Mianyang, China
- Correspondence to Hua-ping Huang, R.N. Nursing Administration, Mianyang Central Hospital, No. 12, Changjia Alley, Jingzhong Street, Fucheng District, Mianyang 621000, China Tel: +86-816-223-9671 Fax: +86-816-222-2566 E-mail:
| | - Bin Chen
- Intensive Care Unit, Mianyang Central Hospital, Mianyang, China
| | - Hai-Yan Wang
- Nursing Administration, Mianyang Central Hospital, Mianyang, China
| | - Me He
- Nursing Administration, Mianyang Central Hospital, Mianyang, China
| |
Collapse
|
50
|
Borden TC, Bellaire LL, Fletcher ND. Improving perioperative care for adolescent idiopathic scoliosis patients: the impact of a multidisciplinary care approach. J Multidiscip Healthc 2016; 9:435-445. [PMID: 27695340 PMCID: PMC5028162 DOI: 10.2147/jmdh.s95319] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
The complex nature of the surgical treatment of adolescent idiopathic scoliosis (AIS) requires a wide variety of health care providers. A well-coordinated, multidisciplinary team approach to the care of these patients is essential for providing high-quality care. This review offers an up-to-date overview of the numerous interventions and safety measures for improving outcomes after AIS surgery throughout the perioperative phases of care. Reducing the risk of potentially devastating and costly complications after AIS surgery is the responsibility of every single member of the health care team. Specifically, this review will focus on the perioperative measures for preventing surgical site infections, reducing the risk of neurologic injury, minimizing surgical blood loss, and preventing postoperative complications. Also, the review will highlight the postoperative protocols that emphasize early mobilization and accelerated discharge.
Collapse
Affiliation(s)
- Timothy C Borden
- Department of Orthopaedic Surgery, Emory University, Atlanta, GA, USA
| | - Laura L Bellaire
- Department of Orthopaedic Surgery, Emory University, Atlanta, GA, USA
| | | |
Collapse
|