514842
BJI15110.1177/1757177413514842Journal of Infection PreventionReport
Infection Prevention 2013 – a potted overview Jonathan A Otter Centre for Clinical Infection and Diagnostics Research (CIDR), Guy’s and St Thomas’ NHS Foundation Trust & King’s College London, Department of Infection, 5th Floor, North Wing, St. Thomas’ Hospital, London, SE1 7EH, UK.; Bioquell UK Ltd; Infection Prevention Society Scientific Programme Committee. Email: [email protected]
Opening lectures – Tricia Hart, Dale Fisher, Michael Gardam, Hugo Sax and Martin Kiernan Following a short opening address from newly appointed Infection Prevention Society (IPS) patron Professor Tricia Hart, exhorting us to put our patients before the numbers, Professor Dale Fisher from Singapore took the stage to talk about gaining organisational buyin. With seamless reference to Pirates of the Caribbean throughout, most memorably, ‘It’s not the problem that’s the problem; it’s your attitude to the problem that’s the problem’ [Captain Jack Sparrow], Professor Fisher gave useful advice on gaining buy-in from all stakeholders, not just administrators. An interesting idea was to incentivise hand hygiene compliance by offering a substantial tax rebate. Another was to embrace the power of the media rather than running away scared. But, whatever you do, don’t be seen as a ‘rigid, dour zealot’. Dr Michael Gardam from Canada was outstanding in his content and delivery on using frontline ownership to deliver patient safety. His resonating theme was ‘culture eats strategy for breakfast’. Dr Gardam drew a thoughtful parallel between healthcare and raising children: challenging, private, rewarding, unpredictable, fun. This illustrated the ‘individuality’ of healthcare; each patient is different and should be treated individually. Equally, to achieve effective culture change, you need to empower the changee. Professor Hugo Sax from Switzerland challenged the traditional approach of: perform hand hygiene ‘education’ and then if that fails, educate some more and if that fails, make education mandatory! A consideration of fundamental human limitations was helpful: our finite capacity to process information per time unit; we are more likely to behave when being observed; and physiological responses affect our behaviour (e.g. olfactory cues (Birnbach et al, 2013)). These socalled ‘human factors’ must be embedded in our approaches to promote hand hygiene compliance. To round off the morning’s lectures, Martin Kiernan delivered the EM Cotterall Lecture, revealing the life and times of the urinary catheter. Typically animated and innovative (including live tweeting as he was speaking), Martin outlined the challenges surrounding urinary catheters, including non-infectious risks. There is a remarkable lack of data and heterogeneity of practice for such a high-risk healthcare intervention.
Report
2014
Submitted oral presentations: hand hygiene compliance and MRSA control Paul Alper (Deb Ltd) presented an electronic system for monitoring hand hygiene compliance (Alper et al, 2013). The initial data look great, but the success or failure of the system depends on the accuracy of the denominator, which is derived from anticipated hand hygiene opportunities. It does seem that the subjectivity and
Hawthorne effect of hand hygiene monitoring would be reduced or perhaps even eliminated through automating the process. Carolyn Dawson (University of Warwick) considered triggers for hand hygiene, with overtones of Professor Sax’s opening lecture (Dawson, 2013). Inherent (‘urgh’) triggers are more powerful than elective (‘taught’) triggers, hence inherent activities result in better compliance. We need to harness these fundamental human factors to achieve the highest possible rates of compliance. Next up, I presented some work on meticillin-resistant Staphylococcous aureus (MRSA) admission screening at St Thomas’ in London (Otter, 2013a). An informal poll of the audience revealed that, surprisingly, the majority thought that targeted screening would detect less than 50% of carriers. Our study calculated that reverting from universal MRSA admission screening to a targeted approach would result in 75% (almost 22,000) less screens but 45% (262) undetected MRSA carriers admitted. Is this enough to reconsider scrapping universal MRSA screening and returning to a targeted approach? Debbie Weston (Kent) experienced a sizeable outbreak of mupirocin-resistant MRSA, affecting 144 patients over 10 months (Weston et al, 2013). Among other interventions, the team made a sensible switch from mupirocin to fusidic acid and Octenisan for MRSA decolonisation and screened staff for MRSA carriage. Five staff carriers were detected, which could have been a factor in the continuation of the outbreak. This outbreak brings into sharp focus the risk of universal application of mupirocin to ICU patients in a recent US study (Huang et al, 2013). Multidrug-resistant Gram-negatives An important forum for discussing the challenges presented by multidrug-resistant Gram-negatives began with Profesor Peter Wilson (UCLH) summarising: Issues driving the ‘next MRSA’: antibiotic abuse in humans and animals; gastrointestinal carriage; complex, challenging sources; and rapid transmission. [Scant] evidence for effective interventions: screening; isolation; staffing; enhanced disinfection (consider hydrogen peroxide vapour); antibiotic stewardship; ward closure (perhaps). Research needs: gastrointestinal carriage rates; importance of imported cases; selective digestive decontamination (SDD); human vs. animal transmission; how best to improve cleaning. Craig Bradley (Birmingham) then related his experience of controlling outbreaks of multidrug-resistant Acinetobacter baumannii highlighting the importance of environmental disinfection, and Alice Nutbourne
© The Author(s) 2014
Reprints and permissions: http://www.sagepub.co.uk/journalsPermissions.nav 10.1177/1757177413514842
VOL. 15 NO. 1 January 2014
Journal of Infection Prevention
9
(King’s, London) warned that empirical antibiotic therapy may be ineffective for an increasing proportion of Gram-negative sepsis cases. Medical stats with Tim Boswell Dr Tim Boswell (Nottingham) provided a useful, practical overview of how to tell whether an observed difference is due to chance. Covering theory, an overview and appraisal of available software and worked examples, this session provided a framework for understanding the difference between clinical and statistical significance. Copper surfaces, ‘no-touch’ automated room disinfection (NTD) and single rooms Professor Tom Elliot (Birmingham) presented the impressive and ever-accumulating evidence for the introduction of copper surfaces in healthcare. It is useful to note that one cited paper from the 1980s showed that brass door handles were less likely to be contaminated than stainless steel ones, so the concept is hardly new (Kuhn, 1983). The data for copper surfaces are now impressive, with the Salgado study suggesting clinical impact (Salgado et al, 2013). However, I still have questions over acceptability, durability and cost effectiveness. Gail Locock (Maidstone) then continued the estates’ theme with a view from her hospital, which has 100% single rooms. An image showing patients ‘so close together they could hold hands’ perhaps best explained the reason why the switch to 100% single rooms was made. Although the infection prevention benefits of 100% single rooms are obvious, challenges include: patient visibility and associated safety, managing dementia, complacency, cleaning turnaround times, auditing compliance with hand hygiene and cohorting difficulties. Gail’s conclusion: pros and cons! Professor Fisher concluded the estates’ theme by addressing whether it is time to turn to ‘no-touch’ automated room disinfection (NTD). He outlined the rationale for considering an NTD system; principally the ‘prior room occupancy’ data combined with the fact that conventional methods do not reliably eliminate pathogens (Otter et al, 2013b). Several different NTD systems are available (mainly hydrogen peroxide vapour or aerosol, and ultraviolet C or pulsed-xenon), each with advantages and disadvantages (Otter et al, 2013c). Technology can help, but you need to understand the limitations. In a way, NTD systems have redefined the standard for hospital hygiene, but workflows need to be adjusted if they are to be successfully implemented.
Report
Submitted oral presentations: ‘Get Stoolsmart’ and hub contamination The impressive and Twitter-innovating Coventry IPS team gave an entertaining overview of their ‘Get Stoolsmart’ campaign, aiming to return clinical judgment to frontline clinicians (with overtones of Dr Gardam’s opening lecture) (Bradley et al, 2013). Dr Maryanne Mariyaselvam (King’s Lynn) found that 90% of needle-free IV connectors were contaminated with bacteria whereas only 33% of open hubs remained contaminated after flushing (Richardson et al, 2013). What’s the answer? ‘Scrub the hub’ or new technology (including the connector impregnated with an antimicrobial under development by Dr Mariyaselvam and colleagues)? Infection prevention and control in Japan – Professor Kobayashi Professor Kobayashi (or ‘Kobayashi-sensei’!) provided a historical perspective on the development of an infection prevention and control programme in Japan. As a cardiac surgeon turned IPC champion, Professor Kobayashi has decades of experience to relate. Ultrasonic
10 Journal of Infection Prevention
January 2014 VOL. 15 NO. 1
chlorhexidine baths for hand hygiene turned out to be a bad idea due to Gram-negative contamination, but the implementation of hand gels, link nurse programmes and temporary side rooms in Japan under the expert stewardship of Professor Kobayashi were years ahead of their time. International forum on infection prevention and control Internationally renowned speakers representing Asia (Professor Dale Fisher), the USA (Robert Garcia), Europe (Professor Hugo Sax) and England (Carole Fry) presented their biggest IPC successes and challenges:
Successes
Challenges
Asia
• Bundles • MRSA and VRE control • Hand hygiene
USA
• VAP and CLABSI reductions
Europe
• ECDC point prevalence survey
England
• MRSA reductions
• Slow response to CRE • Lack of infrastructure to manage a pandemic • Adopting ‘ventilator associated events’ (VAE) • CLABSI-related decolonisation • Uneven distribution of wealth, staff, ABX use, hand hygiene and healthcareassociated infections • Multidrug-resistant Gram-negatives • Behaviour change • Sustainability
ABX = antibiotic; CRE = carbapenem-resistant Enterobacteriaceae; VRE = vancomycin-resistant enterococci; VAP = ventilator-associated pneumonia; CLABSI = central-line associated bloodstream infection
It was encouraging to hear the experts celebrating their success, sharing ideas and embracing the challenges. From my viewpoint, the common challenge is the threat of carbapenem-producing enterobacteriaceae (CPE), which has the potential to spread globally like wildfire and make antibiotics virtually redundant. Peter Hoffman on wipes There has been an explosion in the use of detergent and disinfectant impregnated wipes for hospital disinfection. Parents of young children in particular will understand the convenience of wipes over ‘wet bucket’ approaches. But how do the data look in terms of efficacy? Peter Hoffman (PHE) outlined the challenges for wipes including: variations in microbial susceptibility, dealing with soiling, achieving adequate contact time with a small amount of moisture, large/intricate areas, choosing an appropriate active chemical, and the dangers of sequential wiping transferring contamination. Importantly, Peter demonstrated that adding a sporicidal chemical to a wipe does not necessarily make a sporicidal wipe. Depressingly, it seems that choosing disinfectant wipes currently relies on manufacturers’ data using non-comparable testing. Conventional suspension tests and surface tests are meaningless for wipes so an accepted standard test for wipes is required urgently.
Keynote addresses – Jane Cummings, Aidan Halligan The Chief Nursing Officer (England), Jane Cummings, spoke on unravelling and harnessing the potential of the complex ‘new’ NHS. The address included discussion on a new initiative: ‘6Cs Live’, which looks like an invaluable resource. She concluded with a powerful patient-centred video entitled ‘Empathy’ (from Wrightington, Wigan and Leigh NHS Foundation Trust). The video aptly introduced the theme of Professor Aidan Halligan’s address on rediscovering lost values in the NHS. Professor Halligan was disarmingly honest and forthright about the need to put patients first, poignantly citing Martin Luther King: ‘Our lives begin to end the moment we become silent about things that matter’. Focusing on empathy and compassion, and having the courage to challenge poor behaviour in a ward environment that can sometimes feel like a warzone is challenging and mistakes will be made. But try we must! Submitted oral presentations –CPE at King’s and HPV at Tommies Anita Verma (King’s, London) discussed the challenges of managing an outbreak of VIM-producing CPE on a paediatric unit affecting 11 patients in 2012 (Verma et al, 2013). The outbreak response included the development of a detailed care plan, enhanced cleaning and transfer guidance for other hospitals. Despite several challenges (including poor adherence to IPC standards; suboptimal cleaning and disinfection; lack of awareness by caregivers, staff and visitors; and young patients in nappies), the outbreak was successfully controlled. David Tucker (Guy’s and St Thomas’, London) described a comparison between the length of time and cost of disinfecting rooms and bays using conventional methods or hydrogen peroxide vapour (HPV) (Tucker and Chappel, 2013). Surprisingly, the HPV process time (including pre-cleaning) was only marginally longer for rooms and bays, and HPV was marginally more expensive for rooms and cheaper for bays. These findings are at odds with the general perception that HPV takes considerably longer and is much more expensive than conventional methods. Clostridium difficile – search and destroy Search – Dr Simon Goldenberg (Guy’s and St Thomas’, London) addressed some problematic epidemiological definitions for Clostridium difficile, which result in confusion and make true community-acquired C. difficile infection ‘CA-CDI’ difficult to identify. Relatively recent data on C. difficile testing suggests that ‘you’d be better off flipping a coin than using some toxin EIA tests for CDI diagnosis’. Fortunately, DH diagnosis guidelines are now clear (Department of Health, 2012)! Destroy – Myth-busting Dr Jimmy Walker (PHE) provided some invaluable advice on choosing a sporicide active against C. difficile. Practically speaking, Dr Walker reminded us of the need for effective cleaning before disinfection for both disinfectant activity and aesthetics, and to look out for material compatibility problems when using
Report
References Alper P, Diller T, Steed C, Kelly W, Boeker S, Blackhurst D. (2013) Electronic monitoring of hand hygiene for the WHO 5-moments method. Journal of Infection Prevention 14(S1): S6. Birnbach DJ, King D, Vlaev I, Rosen LF, Harvey PD (2013) Impact of environmental olfactory cues on hand hygiene behaviour in a simulated hospital environment: a randomized study. Journal of Hospital Infection 85: 79–81.
sporicides. Specifying appropriate in vitro tests for sporcidies is challenging, but a 60 minute contact time is completely unrepresentative: you’d be lucky to achieve six minutes in the field – six second is probably more realistic. Dr Walker urged us not to be passive purchasers, but to check and challenge manufacturers’ (sometimes bogus) sporicidal claims. Closing lectures – Barry Cookson, Phil Hammond, Didier Pittet and Julie Storr Professor Barry Cookson delivered the Ayliffe Lecture on the past, present and future of MRSA. Professor Cookson described the 1970s as the decade of complacency, the 1980s of re-emergence, the 1990s of dawning realisation, the 2000s of reactivity and the 2010s of uncertainty. My alternative view is: 1970s close shave; 1980s warning signs; 1990s unchecked; 2000s action, finally; 2010s ‘post’ MRSA era. The conclusion was to learn from the past to safeguard the future, with Professor Cookson remaining fearful of future failure if effective surveillance systems are not in place and maintained. Dr Phil Hammond lit up the room with his insightful and, at times, downright hilarious commentary on speaking the truth to power; on not commoditising healthcare; on restructuring the NHS; on dark stories about gagging whistleblowers; and on transparency. His summary: the ‘top-down’ restructuring of the NHS has failed; we need to develop care partnerships with our patients. Newly appointed patron Professor Didier Pittet inspired us to begin with the end in mind, focusing on what we want to be and do, followed by final uplifting words from Julie Storr, the IPS President. Overriding themes Infection Prevention 2013 provided some useful food for thought and discussion: Try new ways to achieve culture change (for example, empowering your culture changees [Gardam], embracing the media [Fisher], and ‘putting the love back into infection prevention and control’ [the irrepressible Coventry IPC team]). Where and when can automation help (monitoring hand hygiene compliance, terminal disinfection)? What on earth do we do about multidrug-resistant Gram-negatives, specifically CPE? How to do more for less, maximise the opportunities of the ‘new’ NHS, while retaining compassion and empathy as core values? Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Declaration of Conflicting Interest The author declares that there is no conflict of interest.
Bradley A, Stuart S, Prevc K, Reakes-Wells F. (2013) “Get Stoolsmart” campaign. Journal of Infection Prevention 14(S1): S3. Dawson C (2013) To “Urgh” is human… exploring inherent and elective hand hygiene triggers: a pilot study in the NHS. Journal of Infection Prevention14(S1): S4. Department of Health. (2012) Updated guidance on the diagnosis and reporting of Clostridium difficile. Available at: http://www.dh.gov. uk/publications
VOL. 15 NO. 1 January 2014
Journal of Infection Prevention
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Report
Huang SS, Septimus E, Kleinman K, Moody J, Hickok J, Avery TR, Lankiewicz J, Gombosev A, Terpstra L, Hartford F, Hayden MK, Jernigan JA, Weinstein RA, Fraser VJ, Haffenreffer K, Cui E, Kaganov RE, Lolans K, Perlin JB, Platt R, The CDC Prevention Epicenters Program, The ADN & Healthcare-Associated Infections Program. (2013) Targeted versus universal decolonization to prevent ICU infection. New England Journal of Medicine 368: 2255–65. Kuhn P. (1983) Doorknobs: a source of nosocomial infection? Diagn Med Nov/Dec: 62–3. Otter JA, Tosas O, Herdman T, Williams B, Tucker D, Edgeworth JD, French GL. (2013a) Targeted MRSA admission screening would fail to identify almost half of carriers in a London Hospital. Journal of Infection Prevention 14(S1): S4. Otter JA, Yezli S, Salkeld JA, French GL. (2013b) Evidence that contaminated surfaces contribute to the transmission of hospital pathogens and an overview of strategies to address contaminated surfaces in hospital settings. American Journal of Infection Control 41: S6–S11. Otter JA, Yezli S, Perl TM, Barbut F, French GL (2013c) Is there a role for “no-touch” automated room disinfection systems in infection prevention and control? Journal of Hospital Infection 83: 1–13.
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January 2014 VOL. 15 NO. 1
Richardson J, Hodges E, Rogerson G, Mariyaselvam M, Maduakor C, Young P. (2013) Bacterial colonisation and transmission risk of intravenous connectors. Journal of Infection Prevention14(S1): S6. Salgado CD, Sepkowitz KA, John JF, Cantey JR, Attaway HH, Freeman KD, Sharpe PA, Michels HT, Schmidt MG. (2013) Copper surfaces reduce the rate of healthcare-acquired infections in the intensive care unit. Infection Control and Hospital Epidemiology 34: 479–86. Tucker D, Chappel J. (2013) Hydrogen peroxide vapour (HPV) room disinfection is faster and often cheaper than conventional deep cleaning. Journal of Infection Prevention 14(S1): S7. Verma A, Fife A, Baker A, Harris S, Desai N, Graver M, Farren M, Wade J, Philpott-Howard P, Dhawan A. (2013) Challanges in management of VIM-4 carbapenemase producing Enterobacteriaceae in a paediatric unit. Journal of Infection Prevention 14(S1): S5. Weston D, Taborn E, Roberts S, Maskell C. (2013) An outbreak of a new mupirocin-resistant meticillin-resistant Staphylococcus aureus (MRSA) clone at a district general hospital in a large acute NHS trust in the south-east of England in 2011–2012. Journal of Infection Prevention 14(S1): S4.
BJI15110.1177/1757177413514842Journal of Infection PreventionReport
Infection Prevention 2013 – a potted overview Jonathan A Otter Centre for Clinical Infection and Diagnostics Research (CIDR), Guy’s and St Thomas’ NHS Foundation Trust & King’s College London, Department of Infection, 5th Floor, North Wing, St. Thomas’ Hospital, London, SE1 7EH, UK.; Bioquell UK Ltd; Infection Prevention Society Scientific Programme Committee. Email: [email protected]
Opening lectures – Tricia Hart, Dale Fisher, Michael Gardam, Hugo Sax and Martin Kiernan Following a short opening address from newly appointed Infection Prevention Society (IPS) patron Professor Tricia Hart, exhorting us to put our patients before the numbers, Professor Dale Fisher from Singapore took the stage to talk about gaining organisational buyin. With seamless reference to Pirates of the Caribbean throughout, most memorably, ‘It’s not the problem that’s the problem; it’s your attitude to the problem that’s the problem’ [Captain Jack Sparrow], Professor Fisher gave useful advice on gaining buy-in from all stakeholders, not just administrators. An interesting idea was to incentivise hand hygiene compliance by offering a substantial tax rebate. Another was to embrace the power of the media rather than running away scared. But, whatever you do, don’t be seen as a ‘rigid, dour zealot’. Dr Michael Gardam from Canada was outstanding in his content and delivery on using frontline ownership to deliver patient safety. His resonating theme was ‘culture eats strategy for breakfast’. Dr Gardam drew a thoughtful parallel between healthcare and raising children: challenging, private, rewarding, unpredictable, fun. This illustrated the ‘individuality’ of healthcare; each patient is different and should be treated individually. Equally, to achieve effective culture change, you need to empower the changee. Professor Hugo Sax from Switzerland challenged the traditional approach of: perform hand hygiene ‘education’ and then if that fails, educate some more and if that fails, make education mandatory! A consideration of fundamental human limitations was helpful: our finite capacity to process information per time unit; we are more likely to behave when being observed; and physiological responses affect our behaviour (e.g. olfactory cues (Birnbach et al, 2013)). These socalled ‘human factors’ must be embedded in our approaches to promote hand hygiene compliance. To round off the morning’s lectures, Martin Kiernan delivered the EM Cotterall Lecture, revealing the life and times of the urinary catheter. Typically animated and innovative (including live tweeting as he was speaking), Martin outlined the challenges surrounding urinary catheters, including non-infectious risks. There is a remarkable lack of data and heterogeneity of practice for such a high-risk healthcare intervention.
Report
2014
Submitted oral presentations: hand hygiene compliance and MRSA control Paul Alper (Deb Ltd) presented an electronic system for monitoring hand hygiene compliance (Alper et al, 2013). The initial data look great, but the success or failure of the system depends on the accuracy of the denominator, which is derived from anticipated hand hygiene opportunities. It does seem that the subjectivity and
Hawthorne effect of hand hygiene monitoring would be reduced or perhaps even eliminated through automating the process. Carolyn Dawson (University of Warwick) considered triggers for hand hygiene, with overtones of Professor Sax’s opening lecture (Dawson, 2013). Inherent (‘urgh’) triggers are more powerful than elective (‘taught’) triggers, hence inherent activities result in better compliance. We need to harness these fundamental human factors to achieve the highest possible rates of compliance. Next up, I presented some work on meticillin-resistant Staphylococcous aureus (MRSA) admission screening at St Thomas’ in London (Otter, 2013a). An informal poll of the audience revealed that, surprisingly, the majority thought that targeted screening would detect less than 50% of carriers. Our study calculated that reverting from universal MRSA admission screening to a targeted approach would result in 75% (almost 22,000) less screens but 45% (262) undetected MRSA carriers admitted. Is this enough to reconsider scrapping universal MRSA screening and returning to a targeted approach? Debbie Weston (Kent) experienced a sizeable outbreak of mupirocin-resistant MRSA, affecting 144 patients over 10 months (Weston et al, 2013). Among other interventions, the team made a sensible switch from mupirocin to fusidic acid and Octenisan for MRSA decolonisation and screened staff for MRSA carriage. Five staff carriers were detected, which could have been a factor in the continuation of the outbreak. This outbreak brings into sharp focus the risk of universal application of mupirocin to ICU patients in a recent US study (Huang et al, 2013). Multidrug-resistant Gram-negatives An important forum for discussing the challenges presented by multidrug-resistant Gram-negatives began with Profesor Peter Wilson (UCLH) summarising: Issues driving the ‘next MRSA’: antibiotic abuse in humans and animals; gastrointestinal carriage; complex, challenging sources; and rapid transmission. [Scant] evidence for effective interventions: screening; isolation; staffing; enhanced disinfection (consider hydrogen peroxide vapour); antibiotic stewardship; ward closure (perhaps). Research needs: gastrointestinal carriage rates; importance of imported cases; selective digestive decontamination (SDD); human vs. animal transmission; how best to improve cleaning. Craig Bradley (Birmingham) then related his experience of controlling outbreaks of multidrug-resistant Acinetobacter baumannii highlighting the importance of environmental disinfection, and Alice Nutbourne
© The Author(s) 2014
Reprints and permissions: http://www.sagepub.co.uk/journalsPermissions.nav 10.1177/1757177413514842
VOL. 15 NO. 1 January 2014
Journal of Infection Prevention
9
(King’s, London) warned that empirical antibiotic therapy may be ineffective for an increasing proportion of Gram-negative sepsis cases. Medical stats with Tim Boswell Dr Tim Boswell (Nottingham) provided a useful, practical overview of how to tell whether an observed difference is due to chance. Covering theory, an overview and appraisal of available software and worked examples, this session provided a framework for understanding the difference between clinical and statistical significance. Copper surfaces, ‘no-touch’ automated room disinfection (NTD) and single rooms Professor Tom Elliot (Birmingham) presented the impressive and ever-accumulating evidence for the introduction of copper surfaces in healthcare. It is useful to note that one cited paper from the 1980s showed that brass door handles were less likely to be contaminated than stainless steel ones, so the concept is hardly new (Kuhn, 1983). The data for copper surfaces are now impressive, with the Salgado study suggesting clinical impact (Salgado et al, 2013). However, I still have questions over acceptability, durability and cost effectiveness. Gail Locock (Maidstone) then continued the estates’ theme with a view from her hospital, which has 100% single rooms. An image showing patients ‘so close together they could hold hands’ perhaps best explained the reason why the switch to 100% single rooms was made. Although the infection prevention benefits of 100% single rooms are obvious, challenges include: patient visibility and associated safety, managing dementia, complacency, cleaning turnaround times, auditing compliance with hand hygiene and cohorting difficulties. Gail’s conclusion: pros and cons! Professor Fisher concluded the estates’ theme by addressing whether it is time to turn to ‘no-touch’ automated room disinfection (NTD). He outlined the rationale for considering an NTD system; principally the ‘prior room occupancy’ data combined with the fact that conventional methods do not reliably eliminate pathogens (Otter et al, 2013b). Several different NTD systems are available (mainly hydrogen peroxide vapour or aerosol, and ultraviolet C or pulsed-xenon), each with advantages and disadvantages (Otter et al, 2013c). Technology can help, but you need to understand the limitations. In a way, NTD systems have redefined the standard for hospital hygiene, but workflows need to be adjusted if they are to be successfully implemented.
Report
Submitted oral presentations: ‘Get Stoolsmart’ and hub contamination The impressive and Twitter-innovating Coventry IPS team gave an entertaining overview of their ‘Get Stoolsmart’ campaign, aiming to return clinical judgment to frontline clinicians (with overtones of Dr Gardam’s opening lecture) (Bradley et al, 2013). Dr Maryanne Mariyaselvam (King’s Lynn) found that 90% of needle-free IV connectors were contaminated with bacteria whereas only 33% of open hubs remained contaminated after flushing (Richardson et al, 2013). What’s the answer? ‘Scrub the hub’ or new technology (including the connector impregnated with an antimicrobial under development by Dr Mariyaselvam and colleagues)? Infection prevention and control in Japan – Professor Kobayashi Professor Kobayashi (or ‘Kobayashi-sensei’!) provided a historical perspective on the development of an infection prevention and control programme in Japan. As a cardiac surgeon turned IPC champion, Professor Kobayashi has decades of experience to relate. Ultrasonic
10 Journal of Infection Prevention
January 2014 VOL. 15 NO. 1
chlorhexidine baths for hand hygiene turned out to be a bad idea due to Gram-negative contamination, but the implementation of hand gels, link nurse programmes and temporary side rooms in Japan under the expert stewardship of Professor Kobayashi were years ahead of their time. International forum on infection prevention and control Internationally renowned speakers representing Asia (Professor Dale Fisher), the USA (Robert Garcia), Europe (Professor Hugo Sax) and England (Carole Fry) presented their biggest IPC successes and challenges:
Successes
Challenges
Asia
• Bundles • MRSA and VRE control • Hand hygiene
USA
• VAP and CLABSI reductions
Europe
• ECDC point prevalence survey
England
• MRSA reductions
• Slow response to CRE • Lack of infrastructure to manage a pandemic • Adopting ‘ventilator associated events’ (VAE) • CLABSI-related decolonisation • Uneven distribution of wealth, staff, ABX use, hand hygiene and healthcareassociated infections • Multidrug-resistant Gram-negatives • Behaviour change • Sustainability
ABX = antibiotic; CRE = carbapenem-resistant Enterobacteriaceae; VRE = vancomycin-resistant enterococci; VAP = ventilator-associated pneumonia; CLABSI = central-line associated bloodstream infection
It was encouraging to hear the experts celebrating their success, sharing ideas and embracing the challenges. From my viewpoint, the common challenge is the threat of carbapenem-producing enterobacteriaceae (CPE), which has the potential to spread globally like wildfire and make antibiotics virtually redundant. Peter Hoffman on wipes There has been an explosion in the use of detergent and disinfectant impregnated wipes for hospital disinfection. Parents of young children in particular will understand the convenience of wipes over ‘wet bucket’ approaches. But how do the data look in terms of efficacy? Peter Hoffman (PHE) outlined the challenges for wipes including: variations in microbial susceptibility, dealing with soiling, achieving adequate contact time with a small amount of moisture, large/intricate areas, choosing an appropriate active chemical, and the dangers of sequential wiping transferring contamination. Importantly, Peter demonstrated that adding a sporicidal chemical to a wipe does not necessarily make a sporicidal wipe. Depressingly, it seems that choosing disinfectant wipes currently relies on manufacturers’ data using non-comparable testing. Conventional suspension tests and surface tests are meaningless for wipes so an accepted standard test for wipes is required urgently.
Keynote addresses – Jane Cummings, Aidan Halligan The Chief Nursing Officer (England), Jane Cummings, spoke on unravelling and harnessing the potential of the complex ‘new’ NHS. The address included discussion on a new initiative: ‘6Cs Live’, which looks like an invaluable resource. She concluded with a powerful patient-centred video entitled ‘Empathy’ (from Wrightington, Wigan and Leigh NHS Foundation Trust). The video aptly introduced the theme of Professor Aidan Halligan’s address on rediscovering lost values in the NHS. Professor Halligan was disarmingly honest and forthright about the need to put patients first, poignantly citing Martin Luther King: ‘Our lives begin to end the moment we become silent about things that matter’. Focusing on empathy and compassion, and having the courage to challenge poor behaviour in a ward environment that can sometimes feel like a warzone is challenging and mistakes will be made. But try we must! Submitted oral presentations –CPE at King’s and HPV at Tommies Anita Verma (King’s, London) discussed the challenges of managing an outbreak of VIM-producing CPE on a paediatric unit affecting 11 patients in 2012 (Verma et al, 2013). The outbreak response included the development of a detailed care plan, enhanced cleaning and transfer guidance for other hospitals. Despite several challenges (including poor adherence to IPC standards; suboptimal cleaning and disinfection; lack of awareness by caregivers, staff and visitors; and young patients in nappies), the outbreak was successfully controlled. David Tucker (Guy’s and St Thomas’, London) described a comparison between the length of time and cost of disinfecting rooms and bays using conventional methods or hydrogen peroxide vapour (HPV) (Tucker and Chappel, 2013). Surprisingly, the HPV process time (including pre-cleaning) was only marginally longer for rooms and bays, and HPV was marginally more expensive for rooms and cheaper for bays. These findings are at odds with the general perception that HPV takes considerably longer and is much more expensive than conventional methods. Clostridium difficile – search and destroy Search – Dr Simon Goldenberg (Guy’s and St Thomas’, London) addressed some problematic epidemiological definitions for Clostridium difficile, which result in confusion and make true community-acquired C. difficile infection ‘CA-CDI’ difficult to identify. Relatively recent data on C. difficile testing suggests that ‘you’d be better off flipping a coin than using some toxin EIA tests for CDI diagnosis’. Fortunately, DH diagnosis guidelines are now clear (Department of Health, 2012)! Destroy – Myth-busting Dr Jimmy Walker (PHE) provided some invaluable advice on choosing a sporicide active against C. difficile. Practically speaking, Dr Walker reminded us of the need for effective cleaning before disinfection for both disinfectant activity and aesthetics, and to look out for material compatibility problems when using
Report
References Alper P, Diller T, Steed C, Kelly W, Boeker S, Blackhurst D. (2013) Electronic monitoring of hand hygiene for the WHO 5-moments method. Journal of Infection Prevention 14(S1): S6. Birnbach DJ, King D, Vlaev I, Rosen LF, Harvey PD (2013) Impact of environmental olfactory cues on hand hygiene behaviour in a simulated hospital environment: a randomized study. Journal of Hospital Infection 85: 79–81.
sporicides. Specifying appropriate in vitro tests for sporcidies is challenging, but a 60 minute contact time is completely unrepresentative: you’d be lucky to achieve six minutes in the field – six second is probably more realistic. Dr Walker urged us not to be passive purchasers, but to check and challenge manufacturers’ (sometimes bogus) sporicidal claims. Closing lectures – Barry Cookson, Phil Hammond, Didier Pittet and Julie Storr Professor Barry Cookson delivered the Ayliffe Lecture on the past, present and future of MRSA. Professor Cookson described the 1970s as the decade of complacency, the 1980s of re-emergence, the 1990s of dawning realisation, the 2000s of reactivity and the 2010s of uncertainty. My alternative view is: 1970s close shave; 1980s warning signs; 1990s unchecked; 2000s action, finally; 2010s ‘post’ MRSA era. The conclusion was to learn from the past to safeguard the future, with Professor Cookson remaining fearful of future failure if effective surveillance systems are not in place and maintained. Dr Phil Hammond lit up the room with his insightful and, at times, downright hilarious commentary on speaking the truth to power; on not commoditising healthcare; on restructuring the NHS; on dark stories about gagging whistleblowers; and on transparency. His summary: the ‘top-down’ restructuring of the NHS has failed; we need to develop care partnerships with our patients. Newly appointed patron Professor Didier Pittet inspired us to begin with the end in mind, focusing on what we want to be and do, followed by final uplifting words from Julie Storr, the IPS President. Overriding themes Infection Prevention 2013 provided some useful food for thought and discussion: Try new ways to achieve culture change (for example, empowering your culture changees [Gardam], embracing the media [Fisher], and ‘putting the love back into infection prevention and control’ [the irrepressible Coventry IPC team]). Where and when can automation help (monitoring hand hygiene compliance, terminal disinfection)? What on earth do we do about multidrug-resistant Gram-negatives, specifically CPE? How to do more for less, maximise the opportunities of the ‘new’ NHS, while retaining compassion and empathy as core values? Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Declaration of Conflicting Interest The author declares that there is no conflict of interest.
Bradley A, Stuart S, Prevc K, Reakes-Wells F. (2013) “Get Stoolsmart” campaign. Journal of Infection Prevention 14(S1): S3. Dawson C (2013) To “Urgh” is human… exploring inherent and elective hand hygiene triggers: a pilot study in the NHS. Journal of Infection Prevention14(S1): S4. Department of Health. (2012) Updated guidance on the diagnosis and reporting of Clostridium difficile. Available at: http://www.dh.gov. uk/publications
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Huang SS, Septimus E, Kleinman K, Moody J, Hickok J, Avery TR, Lankiewicz J, Gombosev A, Terpstra L, Hartford F, Hayden MK, Jernigan JA, Weinstein RA, Fraser VJ, Haffenreffer K, Cui E, Kaganov RE, Lolans K, Perlin JB, Platt R, The CDC Prevention Epicenters Program, The ADN & Healthcare-Associated Infections Program. (2013) Targeted versus universal decolonization to prevent ICU infection. New England Journal of Medicine 368: 2255–65. Kuhn P. (1983) Doorknobs: a source of nosocomial infection? Diagn Med Nov/Dec: 62–3. Otter JA, Tosas O, Herdman T, Williams B, Tucker D, Edgeworth JD, French GL. (2013a) Targeted MRSA admission screening would fail to identify almost half of carriers in a London Hospital. Journal of Infection Prevention 14(S1): S4. Otter JA, Yezli S, Salkeld JA, French GL. (2013b) Evidence that contaminated surfaces contribute to the transmission of hospital pathogens and an overview of strategies to address contaminated surfaces in hospital settings. American Journal of Infection Control 41: S6–S11. Otter JA, Yezli S, Perl TM, Barbut F, French GL (2013c) Is there a role for “no-touch” automated room disinfection systems in infection prevention and control? Journal of Hospital Infection 83: 1–13.
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Richardson J, Hodges E, Rogerson G, Mariyaselvam M, Maduakor C, Young P. (2013) Bacterial colonisation and transmission risk of intravenous connectors. Journal of Infection Prevention14(S1): S6. Salgado CD, Sepkowitz KA, John JF, Cantey JR, Attaway HH, Freeman KD, Sharpe PA, Michels HT, Schmidt MG. (2013) Copper surfaces reduce the rate of healthcare-acquired infections in the intensive care unit. Infection Control and Hospital Epidemiology 34: 479–86. Tucker D, Chappel J. (2013) Hydrogen peroxide vapour (HPV) room disinfection is faster and often cheaper than conventional deep cleaning. Journal of Infection Prevention 14(S1): S7. Verma A, Fife A, Baker A, Harris S, Desai N, Graver M, Farren M, Wade J, Philpott-Howard P, Dhawan A. (2013) Challanges in management of VIM-4 carbapenemase producing Enterobacteriaceae in a paediatric unit. Journal of Infection Prevention 14(S1): S5. Weston D, Taborn E, Roberts S, Maskell C. (2013) An outbreak of a new mupirocin-resistant meticillin-resistant Staphylococcus aureus (MRSA) clone at a district general hospital in a large acute NHS trust in the south-east of England in 2011–2012. Journal of Infection Prevention 14(S1): S4.
