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22.10.2014
Widmer AF 1
Andreas F. Widmer, MD,MSAndreas Voss, MD,PhD
Prof. of Medicine & Infectious DiseasesHead, Hospital Epidemiology
University of Basel, Basel, SwitzerlandTask Force Member WHO Patient Safety
Nosocomial InfectionsThe Role of the
Environment
Transmission of Infectious Agents viaAnimate and Inanimate surfaces
Colonized/Infected Host orEnvironmentalReservoir
Animate Surfaces(principally hands)
Inanimate Surfaces(fomites, environmental surfaces,medical and surgical Instruments
Other Vehicles(water, air, food, soil
and insects)
Susceptible Host
Colonized Host Infected Host
Infectious Dose
Interruption viaCleaning/Disinfection/Sterilization
inanimate_environment2_00
Interruption viaHandhygiene/
Antisepsis
22.10.2014
Widmer AF 2
MDROs: Beyond MRSA, VREenvironmentally stable pathogens
Wenzel RP, ICHE 2008;29(11):1012-1018
Timeline showing the progression in the estimated prevalence in the United Statesof antimicrobial resistance for selected pathogen-antimicrobial pairs.
Survival of Pathogens in the EnvironmentType of bacterium Duration of persistence (range)Acinetobacter spp. 3 days to 5 monthsClostridium difficile (spores) 5 monthsEnterococcus spp. Including VRE and VSE 5 days – 4 monthsHaemophilus influenzae 12 daysKlebsiella spp. 2 hours to > 30 monthsListeria spp. 1 day – monthsMycobacterium tuberculosis 1 day – 4 monthsPseudomonas aeruginosa 6 hours – 16 months (on dry floor: 5 weeks )Salmonella typhi 6 hours – 4 weeksSalmonella typhimurium 10 days - 4.2 yearsSalmonella spp. 1 daySerratia marcescens 3 days – 2 months (on dry floor: 5 weeks )Shigella spp. 2 days – 5 monthsStaphylococcus aureus, including MRSA 7 days - 7 monthsStreptococcus pneumoniae 1 – 20 daysStreptococcus pyogenes 3 days – 6.5 months
Kampf G. BMC Infectious Diseases 2006, 6:130
22.10.2014
Widmer AF 3
Survival of Influenza in the Environment
.Walther BA. Biol. Rev. (2004), 79, pp. 849–869
Environmental Surface Disinfection?
• 1 – 2 hours after floor disinfection identical number of bacteriaas prior to disinfection
[Ayliffe GAJ et al. BMJ 1966; 2: 442]
• “There is no difference in hospital-acquired infection rateswhen floors are cleaned with detergent vs. disinfectant“
[Rutala WA et al: J Hosp Infect 2001; 48 Suppl. A: 66]
22.10.2014
Widmer AF 4
Cross-over Aldehyde vs Glucoprotamin disinfection of BoneMarrow Transplant Unit
Recontamination after disinfection
Meinke R. & Widmer AF. Infect Control Hosp Epidemiol. 2012 Nov;33(11):1077-80
v
Cross-over Aldehyd vs Glucoprotamin disinfection of BoneMarrow Transplant Unit.
Recontamination after disinfection
Meinke R. & Widmer AF. Infect Control Hosp Epidemiol. 2012 Nov;33(11):1077-80
Recontamination with enterococci within 0,5-2 hours
22.10.2014
Widmer AF 5
Disinfectant Product SubstitutionsDonskey CJ. AJIC. May 2013
• Six of the 7 interventions were quasi-experimentalstudies in which rates were compared before andafter interventions with no concurrent control group
• Confounding factors not reported (e.g., hand hygieneor Contact Precaution compliance)
• Decrease in the incidence in 6 of 7 studies
22.10.2014
Widmer AF 6
Handhygiene Techniqueold 6 steps / new 3
WHO_Update_Juni_07
http://www.who.int/patientsafety/en/
Chair: Didier PittetWidmer AF.Surgical Hand Hygiene in:WHO Guideline for Hand Hygiene 2009Widmer AF. Infect Control Hosp Epidemiol 2004Widmer AF. Infect Control Hosp Epidemiol 2007Widmer AF. J Hosp Infect 2009Tschudin S & Widmer AF. Crit Care Med 2010Tschudin S & Widmer AF. ICHE 2010Widmer AF. J Hosp Infect 2013Widmer AF. WHO guideline 2014
FREQUENCY OF ACQUISITION OF MRSA ON GLOVED HANDSAFTER CONTACT WITH SKIN AND ENVIRONMENTAL SITES
40 patients, MRSA carriershand contamination was equally likely after contact with commonly examined skin sites
and commonly touched environmental surfaces in patient rooms (40% vs 45%)
Stiefel U, et al. ICHE 2011;32:185-187
No significant difference on contamination rates of gloved handsafter contact with skin or environmental surfaces (40% vs 45%; p=0.59)
% positive gloved hands after contact with skinand environmental sites (A)
mean number of MRSA colonies acquired onhands (B).
22.10.2014
Widmer AF 7
Case-control study of risk factors for human infection withinfluenza A(H7N9) virus in Jiangsu Province, China, 2013
Risk Factor for Human infection A(H7N9)
Eurosurveillance, June 2013;18: Issue 26, 27
Evidence for Airborne Transmission of Acinetobacter ssp
Sedimentation plates placed in rooms of 7 patients’with respiratory infection or colonization
Brooks SE et al. Infect Control Hosp Epidemiol 2000;21:304.
% o
f pla
tes
grow
ing
Aci
neto
bact
er
LetterTo theeditor
22.10.2014
Widmer AF 8
Aerosolization of carbapenem-resistantA. baumannii in a Trauma /Burn ICU
Settings: A 1,500-bed public teaching hospital Miami53 patient areas cultured,12 (22.6%) air positive for A. baumannii11 (91.6%) corresponded to beds occupied by positive patients
Munoz-Price LS. Crit Care Med 2013; 41:1915・918)
A Long-Term Low-Frequency Hospital Outbreak of KPC-ProducingK. pneumoniae Involving a Persisting Environmental Reservoir
Tofteland S,. PLoS ONE 8(3): e59015.
6
10
22.10.2014
Widmer AF 9
Correlation between number of body sites colonisedwith VRE and environmental contamination in the
same room
Marc JM Bonten: The Lancet Volume 348, 1996 1615 - 1619
Design: retrospective cohort study ,10 ICUs, 750-bed teaching hospitalIntervention: targeted feedback using a black-light marker, cleaning clothssaturated with disinfectant via bucket immersion, and increased education
Acquisition of MRSA and VRE was lowered from3.0% to 1.5% for MRSA and from3.0% to 2.2% for VRE (P < .001 for both).
Patients in rooms previously occupied by MRSA carriers had anincreased risk of acquisition during the baseline (3.9% vs 2.9%, P = .03)but not the intervention (1.5% vs 1.5%, P = .79) period.
In contrast, patients in rooms previously occupied by VRE carriershad an increased risk of acquisition during the baseline (4.5% vs2.8%, P = .001) and intervention (3.5% vs 2.0%, P < .001) periods.
Predictors of MRSA and VRE Acquisitionby patients previously occupied by MRSA or VRE
R. Datta et al. Arch Intern Med 2011;171(6):491-94
22.10.2014
Widmer AF 10
Chart showing the increased riskassociated with the prior room occupant
Otter JA Am J Infect Control 2013;41:S6-11.
Chart showing theincreased risk associatedwith the prior roomoccupant. Thefigures of difference in riskare unadjusted based onraw data. Several of thestudies included adjustedmeasures of risk, butthese were not includedbecause of differencesin study design. * Anypatient infected orcolonized with VRE in thetwo weeks prior toadmission. y Theimmediate prior roomoccupant was known tobe infected or colonizedwith VRE.
Scientific American 2008;298:17JAMA 2007;Oct 17
22.10.2014
Widmer AF 11
Survival of MSSA and MRSAon Fabrics and Plastic
0 10 20 30 40 50 60
Cotton
Terry
Blend
Polyester
Polyethylene
MRSA MSSA Neely AN. JCM 2000;38:724-726
Days after exposure
MRSA contaminated Environment
MRSA Urine/woundn = 27
Blood/Sputumn=11
OR P
Surfaces 85 % 36 % 10.1 0.005
Gowns 65 % ND NA NA
Gloves 58 % ND NA NA
Boyce J. ICHE 1997;18:622-7
mrsa2_98
22.10.2014
Widmer AF 12
Environmental control
• Any registeredDisinfectant for surfaces– CE (Europe)– EPA / FDA (USA)
Bacterialspores
(e.g. C. perfr.,B. stearo-
thermophilus)
Mycobacteria(e.g. M. tuberculosisvar. bovis, M.terrae)
Nonlipid or small viruses(e.g. poliovirus, coxsackievirus)
Fungi (e.g. Candida spp.)
Vegetative bacteria (e.g. S. aureus,P. aeruginosa, Salmonella spp.)
Lipid or medium-size viruses(e.g. HSV, CMV, RSV, HIV, CV-urbanii)
Increasing Order of Resistanceof Microorganisms to Disinfectants
resistant
susceptible
Sterilization EN 554
Disinfectant level
sterilant (high leveldisinfectant with pro-longed exposure time)
high level
intermediate level
low level
PRIONS
Widmer AF. in: Manual of Clinical Microbiology.American Society of Microbiology 2006 /2011
Autoclaving134º/18m (?)
22.10.2014
Widmer AF 13
Pathogens of Concern
• Innate Surfaces– Methicillin-resistant S.aureus (MRSA)– C.difficile– Acinetobacter ssp– Vancomycin-resistant Enterococci (VRE)
• Water– Pseudomonas ssp, non-fermenter
• Air– Moulds, es. Aspergillus
Natl Vital Stat Rep 2009;57(14). Hyattsville, MD: US Department of Health and Human Services, CDC; 2009. Availableat http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_14.pdf.
22.10.2014
Widmer AF 14
Cluster von CDAD durchC. difficile Ribotyp 027
Aug
07
Num
ber
of p
atie
nts w
ith.difficile
Rib
otyp
e 02
7
University Hospital Basel
3
2
1
(Felix Platter Hospital)Geriatric Clinics
Mar
07
Apr
07
May
07
June
07
Nov
06
Dec
06
Jan
07
Feb
07
Jul 0
6
Jul 0
7
Aug
06
Sep
06
Oct
06
Fenner, A. F. Widmer, A. Stranden, M. Conzelmann, A. Goorhuis, C. Harmanus, E. J. Kuijper, and R. Frei.First cluster of clindamycin-resistant Clostridium difficile PCR ribotype 027 in Switzerland.Clin Microbiol.Infect. 14 (5):514-515, 2008.L. Fenner, R. Frei, M. Gregory, M. Dangel, A. Stranden, and A. F. Widmer.Epidemiology of CDAD. Eur.J.Clin.Microbiol.Infect.Dis., 2008.
25 Stuhl-Isolate von 16 Pat.4 vom USB
12 vom Felix Platter-Spital
22.10.2014
Widmer AF 15
Risk factors for Dissemination of C.difficile
“Hygiene of patient and underlyging disease(Worsley M.A., JAC 1998;41,suppl C:59-66)
Effectivenes of Environmental Disinfections against spores(floors, devices )
(Jones et al, Lancet;352:505-6/Wilcox and Fawley, Lancet 2000;356:1324)
Compliance with contact isolation of patients with CDAD(Johnson et al, Am J Med 1990;88:137-40/Struelens et al, Am J Med, 1991;91:138S-144S)
Virulence(Wilcox et al, J Hosp Infect 1997;37:331-343)
Immunity of patients(Barbut Bull Soc Fr Microbiol 2002;17 (2)
Antimicrobial use(Wilcox et al, J Hosp Infect Lett. to the Editor 1997, ECCMID Glasgow 2003)
C.difficile_CID_08 Bobulsky GS et al, Clin Infect Dis 2008;46:447-450
CDAD: Colonized patients andTransmission to Gloves of HCWs
C
Frequency of Clostridium difficile contamination of skin sites of 27 patients with C. difficile-associated disease (CDAD) (A) andfrequency of acquisition on sterile gloves after contact with skin sites of a subset of 10 patients (B). C, Typical illustration ofacquisition of C. difficile on sterile gloves after contact with a CDAD-affected patient’s groin. The larger yellow colonies outliningthe fingers are C. difficile. Of note, the patient had showered 1 h before collection of the culture specimen.
Frequency of acquisition on sterilegloves after contact with skin sites of a
subset of 10 patients
Frequency of Clostridium difficile contamination ofskin sites of 27 patients with C. difficile-associateddisease (CDAD)
22.10.2014
Widmer AF 16
Bacterialspores
(e.g. C. perfr.,B. stearo-
thermophilus)
Mycobacteria(e.g. M. tuberculosisvar. bovis, M.terrae)
Nonlipid or small viruses(e.g. poliovirus, coxsackievirus)
Fungi (e.g. Candida spp.)
Vegetative bacteria (e.g. S. aureus,P. aeruginosa, Salmonella spp.)
Lipid or medium-size viruses(e.g. HSV, CMV, RSV, HIV, CV-urbanii)
Increasing Order of Resistanceof Microorganisms to Disinfectants
resistant
susceptible
Sterilization EN 554
Disinfectant level
sterilant (high leveldisinfectant with pro-longed exposure time)
high level
intermediate level
low level
PRIONS
Widmer AF. in: Manual of Clinical Microbiology.American Society of Microbiology 2006 /2011
Autoclaving134º/18m (?)
Does the environment need to be disinfected?
Intervention Reduction of initialcontamination or Incidenceof CDAD
References
Unbuffered hypochlorite (500 ppm)Phosphate buffered hypochlorite(1600 ppm pH 7,6)
5 X
100 X
Kaatz, Am JEpidemiol 1988
Unbuffered 1:10hypochlorite solutions
Before 8.6/1000 pt-dAfter 3.3/1000 pt-d
Mayfield, CID 2000
Diluted aldehyde-containingdisinfectant + other infection controlmeasures
4 X p=0.04Before 1.5/1000 admAfter 0.3/1000 adm
Struelens, Am JMed 1991
Cases with C.difficile:Disinfection with an active disinfectant against spores necessary
No gluoprotamin. No Quats. No AminesWidmer AF & Frei R.. Infect Control Hosp Epidemiol Nov 2003Widmer AF & Frei R. Disinfection. Manual of Clinical Microbiology, ASM 2007 /2011
22.10.2014
Widmer AF 17
Oxygen-releasing Agentse.g. Magnesium monoperoxyphthalate hexahydrate (MMPP) 80.0 g
Directions for useSurfaces 0,5 % - 1 hrs.Surfaces during epidemics (NLV) 4,0 % - 1 hrs.HBV 0,5 % - 5 min.HIV 0,25 % - 5 min.BVDV* (Surrogate virus for Hep C). 0,5 % - 1 min.Rotavirus 0,25 % - 1 min.Poliovirus 1,0 % - 1 hrs.Adeno-, Vaccinia-, Papovaviruses 0,25 % - 5 min.Bacterial spores 1,0 % - 4 hrs.M.tuberculosis 0,5 % - 1 hrs.
Data on file BDF 2003
HPVGenerator
CatalyticConverter
Hydrogen peroxide vapor(HPV)decontamination,
Picture: Courtesy of Johne Boyce, USA
22.10.2014
Widmer AF 18
Picture: Courtesy of Johne Boyce, USA
Incidence of nosocomial CDAD on 5 wards (A–E) that underwent intensivehydrogen peroxide vapor decontamination, during the preintervention period
(gray bars; June 2004 through March 2005) and the intervention period(red bars; June 2005 through March 2006)
Cdiff_medart.ppt Boyce JM et al. ICHE 2008;29:723-9
Inte
rven
tion
perio
d
Inte
rven
tion
perio
d
Inte
rven
tion
perio
d
Inte
rven
tion
perio
d
Inte
rven
tion
perio
d
22.10.2014
Widmer AF 19
Comparison of Hydrogen Peroxide Vapor Decontamination and Bleach Cleaning, Accordingto the Time Required for Each Phase of Disinfection
Otter JA et al, Infect Control Hosp Epidemiol 2009;30(6):Decontamination_ICHE_09.ppt
Note: There were 93 rooms decontaminated with hydrogen peroxide vapor and 64 matched rooms disinfected by use of bleachcleaning. Bold type indicates statistically significant P values (P <.05). The sum of means for the constituent phases may not equalthe mean of the whole data set. Cumulative times were calculated using absolute times and are thus more accurate than the sumof the mean for the constituent phases. NA, not applicable.a Calculated by use of a 2-tailed t test.b Detergent-based cleaning to remove visible dirt prior to hydrogen peroxide vapor decontamination or bleach cleaning for rooms
that were not decontaminated using hydrogen peroxide vapor.c Time required to set up the decontamination equipment was included in the hydrogen peroxide vapor cycle time.d In rooms decontaminated with hydrogen peroxide vapor, a second visit by housekeeping was necessary to make the bed and
prepare the room for the subsequent occupant.
Hydrogen peroxide vapordecontamination, min Bleach cleaning, min
Phase of process Mean Median (range) Mean Median (range) Pa
Room vacant awaiting housekeeping 21 16 (0-180) 34 21 (0–242) .02First cleaning by housekeepingb 24 24 (0-48) 32 29 (8–73) <.001End of first cleaning to set up of hydrogenperoxide vapor system 19 0 (0-265) NA NA
Hydrogen peroxide vapor cyclec 139 135 (102-225) NA NACumulative time from when room was vacatedto end of hydrogen peroxide vapor cycle 206 179 (141-567) NA NA
End of hydrogen peroxide vapor cycle toarrival of housekeeping 42 23 (0-272) NA NA
Second cleaning by housekeepingd 23 24 (0-46) NA NACumulative time for all phases 270 234 (174-838) 67 55 (28-256) <.001End of disinfection process to occupation 198 119 (0-1025) 147 98 (15-1253) .22
What is on that keyboard? Detecting hidden Environ-mentalReservoirs during a C. difficile outbreak NAP1/027
• 20 of 87 (23%) surfaces cultured outside of patient rooms contaminatedwith toxin-producing C difficile.
• 9 of 29 (31%) surfaces in physician areas were contaminated,– 2 of 6 (33%) telephone keypads– 5 of 19 (26%) desktop computers– 2 of 2 doorknobs.
• 1 of 10 (10%) surfaces in nursing areas were contaminated,– 0 of 2 telephones– 1 of 4 (25%) desktop computers– 0 of 2 doorknobs.
• 9 (21%) of portable medical equipment were contaminated– 0 of 1 ultrasound machines– 1 of 5 (20%) pulse oximeter finger probes,– 3 of 9 (33%) portable computers– 2 of 13 (15%) medication carts– 3 of 11 (27%) medication bar code scanners.
Dumford DM. Am J Infect Control. 2009 Feb;37(1):15-9.
22.10.2014
Widmer AF 20
Pathogens of Concern
• Innate Surfaces– Methicillin-resistant S.aureus (MRSA)– C.difficile– Acinetobacter ssp– Vancomycin-resistant Enterococci (VRE)
• Water– Pseudomonas ssp, non-fermenter
• Air– Moulds, es. Aspergillus
Munoz-Price L and Weinstein R.N Engl J Med 2008;358:1271-1281
Reservoirs, Sources, and Transmission Patterns forAcinetobacter in Health Care Facilities
Acinetobacter_NEJM_08
22.10.2014
Widmer AF 21
Acinetobacter outbreaks 1977-2000
13 Studies with a common source outbreak with a respiratory cluster:•Clonal transmission confirmed by PFGE or PCR-based typing
Setting: Common Source:Adult ICUAdult,neonatal and pediatric ICUAdult mixed ICUSurgical and medical ICUAdult ICUNeonatal ICUAdult mixed ICU
Ventilator spirometersReusable ventilator circuitsIn line temperature monitor probesVentilator temperature probes‘Y’ piece of ventilatorSuction catheter and bottlePeak flow meter
Villegas M, Hartstein A. Infect Control Hosp Epidemiol. 2003;24:284-295
Pathogens of Concern
• Innate Surfaces– Methicillin-resistant S.aureus (MRSA)– C.difficile– Acinetobacter ssp– Vancomycin-resistant Enterococci (VRE)
• Water– Pseudomonas ssp, non-fermenter
• Air– Moulds, es. Aspergillus
22.10.2014
Widmer AF 22
VRE ENVIRONMENTALCONTAMINATION
Reference Sites Contaminated Frequency
Karanfil 1992 EKG pressure monitor dials,doorknob
12%
Boyce 1994 Patient gowns, linens,bedrails, IV pumps, BP cuff
28%
Boyce 1995 Patient gowns, linens,bedrails, BP cuff, IV pump
37%
Slaughter 1996 Bed linen, siderails, BP cuffs,bedside tables
7%
Pathogens of Concern
• Innate Surfaces– Methicillin-resistant S.aureus (MRSA)– C.difficile– Acinetobacter ssp– Vancomycin-resistant Enterococci (VRE)
• Water– Pseudomonas ssp, non-fermenter
• Air– Moulds, es. Aspergillus
22.10.2014
Widmer AF 23
Pseudomonas aeruginosa infections inhealth-care facilities (CDC Guideline
2003)
MMWR June 6, 2003 / Vol. 52 / No. RR-10
Nosocomial Outbreaks fromHospital Tap Water
• Legionella spp Kool JL. ICHE. 1999; 20:798-805,
• P.aeruginosa Widmer AF ICAAC 2000 #123
• Stenotrophomonas maltophilia Denton M. AJIC 2000;28 323-324
• Mycobacteria spp. von Reyn CF. Lancet 1994;343:1137-1141
• Acinetobacter spp. Kappstein I. J.Hosp.Infect 44 (1):27-30, 2000.
• S.aureus LeChevallier MW.Appl.Environ.Microbiol. 39 (4):739-742, 1980.
• Moulds Anaissie E. Clin Infect Dis. 2001;33(9):1546-8.
22.10.2014
Widmer AF 24
P.aeruginosaSources of nosocomial infection
• Endogenous :
– Antibiotic exposure: Selection e.g.Amoxicillin/clavulanate
• Exogenous:
– Waterborne via faucets: ICU, hydrotherapy– Iatrogenic: ventilators, humidifiers, endoscopes, IV
solutions, disinfectant, soap, distilled water,
– Cross-colonisation by HCWs (hands) e.g. Afterhandling fresh flowers
P. aeruginosa : Exogenous Source ofEndemic Nosocomial Infection
Nb of pts Nb of Nb of Nb (%) ofSetting (country) (%) genotypes type/pts exogenous
o. ICU 14 (23%) 1 ?1. Burn unit (D) 12 (?) 14 1-5 9 (75%)2. ICU (D) 15 (26%) 11 1 8 (53%)3. ICUs (CH) 132 (6%) 56 ? 60 (45%)4. ICUs (NL) 23 (23%) 11 ? 8 (35%)5. Acute leukemia pts (D) 18 (15%) 12 1 6 (33%)6. ICUs (D) 48 (4%) 42 ? 6 (13%)7. Surgical ICU (D) 18 (18%) 16 1 2 (11%)8. All wards (CH) 51 (8%) 32 1-4 2 (4%)
0: Widmer AF. Clin Infect Dis 19941. S. Pradella et al. Eur. J. Clin. Microbiol. Infect. Dis. 1994,
13:122-82. G. Döring et al., Epidemiol. Infect., 1993, 110:427-363. Blanc, Intensive Care Med 2004;30:1964-84. D.C.J.J. Bergmans et al. Thorax, 1998, 53:1053-8
5. W. Kern et al., Eur. J. Clin. Microbiol. Infect. Dis., 1990,9:257-61
6. H. Grundmann et al. Clin. Microbiol. Inf., 1999, 5:355-637. E. Gruner et al. JID, 1993, 167:1216-208. D.S. Blanc et al., Clin. Microbiol. Inf., 1998, 4:242-7
Slide by M. Strulens
22.10.2014
Widmer AF 25
Geographical and cases distributions P. aeruginosagenotypes isolated from both the faucets and the ICU patients
hospitalized
Blanc_2004
Blanc DS et al. Intensive Care Med 2004;30:1964-8Blanc DS et al. Intensive Care Med 2004;30:1964-8
Faucet Aerator as probable sourceof an epidemic
AAAuuuttthhhooorrr SSSeeettttttiiinnnggg PPPaaatttiiieeennntttsss PPPaaattthhhooogggeeennn RRReeefffeeerrreeennnccceee YYYeeeaaarrr
WWWiiilllsssooonnn NNNuuurrrssseeerrryyy 111 PPP...aaaeeerrruuugggiiinnnooosssaaa JJJAAAMMMAAA 111999666111
CCCrrrooossssss IIICCCUUU 444 PPP...aaaeeerrruuugggiiinnnooosssaaa NNNEEEJJJMMM 111999666666
KKKooolllmmmooosss BBBuuurrrnnnsss 555 PPP...aaaeeerrruuugggiiinnnooosssaaa JJJHHHIII 111999999333
VVVeeerrrwwweeeiiijjj NNNIIICCCUUU 555 SSS...mmmaaallltttoooppphhhiiillliiiaaa EEEpppiii IIInnnfffeeecccttt 111999999888
KKKaaappppppsssttteeeiiinnn PPPeeedddiiiaaatttrrriiicccooonnncccooolllooogggyyy
333 AAA...jjjuuunnniiiiii JJJHHHIII 111999999999
WWWeeebbbeeerrr SSSIIICCCUUU 777 PPP...aaaeeerrruuugggiiinnnooosssaaa AAAJJJIIICCC 111999999999
22.10.2014
Widmer AF 26
0.00
0.20
0.40
0.60
0.80
1.00
1.20
1.40
1.60
1.80
2.00
0
1
2
3
4
5
6
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Anz
ahl P
at. m
it P.
aer
ugin
osa
in B
B
Inzidence P. aeruginosa Bloodstream InfectionsBone Marrow Transplant Unit 01.01.2000 - 25.02.2009
Patients with Pseudomonas BSIs
Incidence density Pseudomonas BSIs
Linear (Incidence density Pseudomonas BSIs)
Impact of Sterile Water Supply onthe Incidence of NosocomialBloodstream Infectios in BMT
patients
63 mineral waterfrom Switzerland, Italy and France21/63 33% positive for Norovirus
only 1 with gas11% of Swiss mineral waters positiveNo correlation with- chemical- type of bottle (plastic / glass) Beuret C. J Food Prot 2000;63:1576-82
22.10.2014
Widmer AF 27
Pathogens of Concern
• Innate Surfaces– Methicillin-resistant S.aureus (MRSA)– C.difficile– Acinetobacter ssp– Vancomycin-resistant Enterococci (VRE)
• Water– Pseudomonas ssp, non-fermenter
• Air– Moulds, esp. Aspergillus
Summary of ventilation specificationsin selected areas of health-care
facilities*
22.10.2014
Widmer AF 28
Incidence of Surgical Site Infections by Type of Air quality inthe OR: Standard vs Laminar Air Flow
0.9031.37
0.6460.918
2.77
7.14
0.98
2.55
0
1
2
3
4
5
6
7
8
Turbulent AirFlow
Laminar Air Flow Turbulent AirFlow
Laminar Air Flow
Infe
ctio
n R
ate
Hip Knee
C. Brandt. &P.GastmeierAnn.Surg. 2008;248:695-700
N=28,623 N=10,966
Analysis fromsurveillance dataAdjusted OR
• Prosthetic valve endocarditis (PVE) due to fast-growing nontuberculous mycobacteria (NTM) hasbeen reported anecdotally. Reports of PVE withslowly growing NTM, however, are lacking. Wepresent here one case of PVE and one case ofbloodstream infection caused by Mycobacteriumchimaera.
• Randomly amplified polymorphic DNA (RAPD)-PCRindicated a relatedness of the two M. chimaerastrains.
• Both patients had heart surgery 2 years apart fromeach other. A nosocomial link was not detected.
22.10.2014
Widmer AF 29
Office of Public Health July 14, 2014
• Bern, 14.07.2014 - Hospitals in Switzerland thatperform open heart surgery have taken measures toincrease patient safety. In rare cases, infections havebeen observed that did not result in illness until someyears after surgery.
• These infections are believed to be due to the use of adevice that is used during cardiac surgery.
• In conjunction with Swissmedic, the Federal Office ofPublic Health has informed all hospitals and cardiacsurgeons about this problem. Immediate measuresare being taken to prevent such infections fromoccurring in future.
http://www.admin.ch/aktuell/00089/index.html?lang=en&msg-id=53774
22.10.2014
Widmer AF 30
Cooler / Heater: all contaminated byM.chimaera
Clinical Data
• 2 Deaths (published)• 4 infections Osteomyelitis after incubation of
1-2 years– Treatment not standarized– Look-back in progress in Switzerland
• No clinical cases from USB and otherUniversities
Andreas F. Widmer, MD,MSWHO - SSI
22.10.2014
Widmer AF 31
Microbiological Data
• >3 Universities positive samples ofM.chimaera in air sampling
• Airsampling at the surgical site– positive when cooler is running– Negative, when not running– Confirmed by at least 2 university hospitals
• Source of M.Chimaera unknown– Not isolated from water– But cooler must be filled with tap water
Andreas F. Widmer, MD,MSWHO - SSI
Andreas F. Widmer, MD,MSWHO - SSI
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10.06.2014 12.06.2014 14.06.2014 16.06.2014 18.06.2014 20.06.2014 22.06.2014 24.06.2014 26.06.2014 28.06.2014
KBE/
1000
L
GKZ allg Bakt Saal 9_Sorin MT82977
Prior surgery
during surgery
OR Table
Up to 60 CFU/m3 at the surgical sie
Laminar air flow (1978)
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Andreas F. Widmer, MD,MSWHO - SSI
Ventilator
compressor
Andreas F. Widmer, MD,MSWHO - SSI
22.10.2014
Widmer AF 33
Phylogenetic tree of M.chimaera
Andreas F. Widmer, MD,MSWHO - SSI
Actions July/Aug 2014• Sterile Water filter• Decontamination of Cooler/heaters by the
manufacturer• After standard disinfection by perfusionist AND
> 1 week not filled with waterrunning 24h with water
• High density of M.chimaera in air sampling• Definite safe method pending• Problem: incubation time for M.chimaera 7
weeks
Andreas F. Widmer, MD,MSWHO - SSI
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Andreas F. Widmer, MD,MSWHO - SSI
Atypical Mycobacteria: an Underestimated Cause of InfectiveEndocarditis on Bioprosthetic Valve
Pres. Time: Sunday, Sep 07, 2014, 11:00 AM - 1:00 PM L-1066
Author(s): C. Bouchiat, A. Boibieux; Hospices Civils de Lyon, Lyon, France
Abstract:
Background: Atypical Mycobacteria infective endocarditis (IE) has been barely described and is uneasy to diagnose. Methods: From January2010 to December 2013, 5 patients presented to the hospital for blood culture-negative IE suspicion, requiring surgery. 16s rDNA PCR-sequencing was performed on the explanted material, followed by specific hsp PCR-sequencing for species confirmation. Demographic, clinical,histopathologic, Ziehl-Neelsen stain, echocardiographic data, treatment and outcome were collected. Results: The cardiac samples of these 5patients were positive to Mycobacterium chelonae (n=4) and M. lentiflavum (n=1). Patients all presented to hospital for heart failure withoutfever 7.1-18.9 months (median=13.1) after biologic prosthetic valve replacement. Echocardiography revealed paravalvular regurgitation due toprosthesis dehiscence for all. Histopathology examination of the explanted material revealed the presence of macroscopic multi-focalulcerations and inflammatory infiltrates in all specimens, associated with giant cells granulomas (n=3), confirming the diagnosis of IE. Ziehl-Neelsen stain showed numerous Acid Fast Bacilli for all patients. Allergic etiology was ruled out by anti-porcine IgE dosages. These infectionswere significantly associated with biologic prostheses (p<0.01) since none of the 390 other samples (74 bioprostheses, 77 mechanicalprostheses, 239 vegetations or native valves) analyzed in our laboratory over the study period was positive to atypical Mycobacteria
Conclusions: We report 5 cases of atypical Mycobacteria IE on biologicprosthesis. It is thus of importance to encourage a systematic Ziehl-Neelsenstain on explanted bio-prosthetic valves in case of blood culture-negative IEsuspicion. Even though the contamination source remains unclear, we canquestion the conditioning process of the explant following its removal frompigs.
Andreas F. Widmer, MD,MSWHO - SSI
22.10.2014
Widmer AF 35
CONCLUSIONS and Personal Remarkson Hospital Environment and Infection Control
• Dirty Hospitals are dirty and potentially infectious• Floors/Surfaces
– Daily cleaning of patient areas standard– Daily disinfection of rooms with patients colonized/infected with pathogens
who should be isolated or high-turn over areas (e.g.ICU)• MRSA,VRE, Acinetobacter,• Highly active disinfection for C.difficile, Norovirus.
• Water– Filtered Water for PSCT or Bone Marrow Transplant Unit and ICUs with
ventilated patients– Regularly clean shower heads
• Air– PSCT/BMT clean air (Laminar air flow ?????)– OR clean air (laminar air flow for orthopedic surgery?)
Hospital-wide incidence of nosocomial CDAD11/ 2003-3/2006.
Cdiff_medart.ppt Boyce JM et al. ICHE 2008;29:723-9
HPV, hydrogen peroxide vapor
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Quantities of Antimicrobials Used During the Preintervention andIntervention Periods
Cdiff_medart.ppt Boyce JM et al. ICHE 2008;29:723-9
1565 Rooms Decontaminated with Hydrogen Per-oxide Vapor from January 2006 -September 2007
Otter JA et al, Infect Control Hosp Epidemiol 2009;30(6):Decontamination_ICHE_09.ppt
Number of rooms decontaminated with hydrogen peroxide vapor and the number of rooms that met the criteria fordecontamination but could not be decontaminated (rooms missed; see Results for details), as well as percentageoccupancy. Data are quarterly, from January 2006 through September 2007.
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Comparison of Hydrogen Peroxide Vapor Decontamination and Bleach Cleaning, Accordingto the Time Required for Each Phase of Disinfection
Otter JA et al, Infect Control Hosp Epidemiol 2009;30(6):Decontamination_ICHE_09.ppt
Note: There were 93 rooms decontaminated with hydrogen peroxide vapor and 64 matched rooms disinfected by use of bleachcleaning. Bold type indicates statistically significant P values (P <.05). The sum of means for the constituent phases may not equalthe mean of the whole data set. Cumulative times were calculated using absolute times and are thus more accurate than the sumof the mean for the constituent phases. NA, not applicable.a Calculated by use of a 2-tailed t test.b Detergent-based cleaning to remove visible dirt prior to hydrogen peroxide vapor decontamination or bleach cleaning for rooms
that were not decontaminated using hydrogen peroxide vapor.c Time required to set up the decontamination equipment was included in the hydrogen peroxide vapor cycle time.d In rooms decontaminated with hydrogen peroxide vapor, a second visit by housekeeping was necessary to make the bed and
prepare the room for the subsequent occupant.
Hydrogen peroxide vapordecontamination, min Bleach cleaning, min
Phase of process Mean Median (range) Mean Median (range) Pa
Room vacant awaiting housekeeping 21 16 (0-180) 34 21 (0–242) .02First cleaning by housekeepingb 24 24 (0-48) 32 29 (8–73) <.001End of first cleaning to set up of hydrogenperoxide vapor system 19 0 (0-265) NA NA
Hydrogen peroxide vapor cyclec 139 135 (102-225) NA NACumulative time from when room was vacatedto end of hydrogen peroxide vapor cycle 206 179 (141-567) NA NA
End of hydrogen peroxide vapor cycle toarrival of housekeeping 42 23 (0-272) NA NA
Second cleaning by housekeepingd 23 24 (0-46) NA NACumulative time for all phases 270 234 (174-838) 67 55 (28-256) <.001End of disinfection process to occupation 198 119 (0-1025) 147 98 (15-1253) .22
Wu_Noro_ICHE_2005.ppt Wu HM et al. ICHE 2005;26:802-10
Onset of symptoms among the case-residents and case employees of a long-term-care facility in Philadelphia during a norovirus outbreak from
Jan/Feb 2003
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Impact of Chloramin with andwithout Ultraviolet on CFUs onContact Plates for Samples (4
Isolation Units
Anderson BM.Infect Control Hosp Epidemiol 2006; 27:729-734
Disinfection with UVC light may significantly reduce environmental bacterialcontamination and thereby protect the next patient housed in an isolation room.UVC disinfection may not be used alone but is a good addition to chemicaldisinfection.
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Environmental fungal pathogens: entryinto and contamination of the
healthcare facility
Microorganisms associated withairborne transmission
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Summary of ventilation specificationsin selected areas of health-care
facilities*
Water and point-of-use fixturesas sources and reservoirs of
waterborne pathogens* (Cont.)
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Water and point-of-use fixtures as sources andreservoirs of waterborne pathogens* (Cont.)