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Talk, modified from one I gave at ICAAC in 2013. I discuss the possibility that environmental coatings and antimicrobial textiles might help limit the spread of pathogens in hospital settings.
Talk, modified from one I gave at ICAAC in 2013. I discuss the possibility that environmental coatings and antimicrobial textiles might help limit the spread of pathogens in hospital settings.
Talk, modified from one I gave at ICAAC in 2013. I discuss the possibility that environmental coatings and antimicrobial textiles might help limit the spread of pathogens in hospital settings.
Fabrics Prevent HAIs?: Current Evidence or Lack There of Eli Perencevich, MD MS Source of HAI In ICU 40-60% Endogenous flora 20-40% Cross infection from hands of HCW 20-25% Antibiotic driven changes in flora 20% Other (including environment) Lower means harder to study 1. Weber DJ and Rutala WA, Infect Control Hosp Epidemiol, May 2013 2. Weinstein RA, Am J Med 1991; 91 (suppl 3B): 179-184S FOR MORE INFO... Endogenous Iceberg 1. Weinstein RA, Am J Med 1991; 91 (suppl 3B): 179-184S FOR MORE INFO... Patient A Patient B Environment & Equipment Healthcare Workers
Linking Environment to Textiles
Contamination of HCW during care of MDRO colonized patient
What role does the environment play in contamination and transmission? 1. Morgan D, et al, Infect Control Hosp Epidemiol 2010; 31:716-721 2. Snyder G, et al, Infect Control Hosp Epidemiol 2008; 29(7):584-589 FOR MORE INFO... Protocol Swab hands prior to entry Observe activities in room Perform environmental cultures Swab gown/ gloves/hands after exit Textile contamination Organism HCW Room Entries Hand + Before (%) Gown and/or Glove + After % Gowns Positive % Hands + After Removal Effectiveness of PPE A. baumannii 1 202 1.5% 38.7% 11.1% 4.5% 88% P. aeruginosa 1 133 0% 8.2% 4.5% 0.7% 90% VRE 2 94 0% 9% 4.3% 0% 100% MRSA 2 81 2% 19% 6.2% 2.6% 85% 1. Morgan D, et al, Infect Control Hosp Epidemiol 2010; 31:716-721 2. Snyder G, et al, Infect Control Hosp Epidemiol 2008; 29(7):584-589 FOR MORE INFO... Environmental Sites Cultured Note: Excluded call buttons Environmental Sampling 71% percent of rooms had positive environmental cultures with organism known to be colonizing patient
78% Acinetobacter 35% VRE 28% MRSA 22% P. aeruginosa 1. Morgan D, et al, Crit Care Med 2012 Apr;40(4):1045-51 FOR MORE INFO... Independent Predictors of HCW Contamination Odds Ratio 95% Confidence Interval Duration in room >5 minutes 2 1.2-3.4* Physical Exam 1.7 1.1-2.8* Contact with ventilator 1.8 1.1-2.8* + Environmental cultures 4.2 2.7-6.5* * All p < 0.05 1. Morgan D, et al, Crit Care Med 2012 Apr;40(4):1045-51 FOR MORE INFO... Patient A Patient B Nosocomial Transmission Environment Equipment Healthcare Workers Transfer of Vancomycin- Resistant Enterococci via Health Care Worker Hands
Amy Dukro et al Arch Intern Med 2005; 165:302-7 VRE from contaminated to clean skin/environmental sites
Cultured intact skin of 22 VRE+ patients Cultured environmental sites in patients rooms before/after HCW visits Cultured HCW hands before/after care PFGE Duckro AN, Arch Intern Med 2005; 165:302-7 FOR MORE INFO... VRE Transfer Healthcare workers touched 151 negative sites after touching a VRE+ site
16 sites (10.6%) became positive for VRE 12 from body sites 9 were either body source or environmental source Remaining had multiple possible sources Duckro AN, Arch Intern Med 2005; 165:302-7 FOR MORE INFO... Patient Source Duckro AN, Arch Intern Med 2005; 165:302-7 FOR MORE INFO... Possible Textile or Coating Target Duckro AN, Arch Intern Med 2005; 165:302-7 FOR MORE INFO... Role of Professional Attire? Contamination in the clinical setting: White coats Study Pathogen N % positive Wong D 1991 S. aureus 100 29 Loh W 2000 S. aureus Acinetobacter 100 5 7 Osawa K 2003 MRSA 14 79 Treakle AM 2008 S. aureus 149 23 Uneke CJ 2010 S. aureus Ps. aeruginosa 103 19 10 Munoz-Price LS 2012 S. aureus Acinetobacter Enterococcus 22 32 32 5 Study Pathogen N % positive Perry C 2001 MRSA VRE 57 14 38 Munoz-Price LS 2012 S. aureus Acinetobacter Enterococcus 97 11 11 3 Krueger CA 2012 S. aureus 268 33 Contamination in the clinical setting: Scrubs & Uniforms Frequency of Laundering Mean frequency (days) Munoz-Price LS et al. Am J Infect Control 2013;41:565-7. N=160 FOR MORE INFO... Options for contaminated apparel? Bare below the elbows Short sleeves, no jewelry/watches/ties/white coats
Access to frequent/free laundering
Antimicrobial fabrics and attire Maintain professional attire Expensive need cost analyses Role in transmission prevention? Benefits of Silver Antimicrobial Scrubs Study Population Design N Findings Freeman AI, 2012 Veterinary Hospital RCT 127 Surface bacterial counts same at 4 & 8 hours
Gro S, 2010 Ambulance, EMS personnel Cross- over 10 Higher contamination out to 7 days with silver in jackets
RCT of antimicrobial scrubs 109 clinicians randomized
Standard (pants, short-sleeved shirt)
Antimicrobial (A): polyester & antimicrobial chemical
Antimicrobial scrub (B): polyester- cotton+silver+two antimicrobial chemicals Burden M et al. J Hospital Med 2013;8(7): 380-385 FOR MORE INFO... No difference in colony counts Total bacterial count after 8 hour day Burden M et al. J Hospital Med 2013;8(7): 380-385 FOR MORE INFO... VTT-003 Scrubs Impregnated fabric with an organosilane-based quaternary ammonium antimicrobial agent and a copolymer emulsion
30 HCW in ICU, randomized, cross-over trial 4 months, crossover at 4 weeks 458 participant weeks studied 2,000 apparel swabs 1,324 hand swabs
Bearman GML et al. Infect Control Hosp Epidemiol 2012:33(3): 268-75 FOR MORE INFO... No difference by scrub type, shift or location swabbed Bearman GML et al. Infect Control Hosp Epidemiol 2012:33(3): 268-75 FOR MORE INFO... No difference in hand contamination Bearman GML et al. Infect Control Hosp Epidemiol 2012:33(3): 268-75 FOR MORE INFO... No difference in hand contamination Bearman GML et al. Infect Control Hosp Epidemiol 2012:33(3): 268-75 FOR MORE INFO... Privacy Curtains The forgotten fomite
Cleaned every 4 months or never Changed when visibly soiled
Often touched AFTER practicing hand hygiene or donning gloves Contamination in the clinical setting: Privacy Curtains Study Pathogen N % positive Ohl M 2012* All MRSA VRE 180 95 21 42 Klakus J 2008 MRSA 200 16 Trillis MRSA VRE C. difficile 50 22 42 4 * 12/13 (92%) new curtains contaminated at 1 week Antimicrobial Privacy Curtains University of Iowa Randomized trial 30 ICU rooms 15 standard vs 15 complex element compound Curtains identical in shape/size Blinded data collection and microbiology Blinded removed post analysis
1. Schweizer ML et al. Infect Control Hosp Epidemiol 2012 (33)11: 1081-85 FOR MORE INFO... Sampling method Curtains sampled 1 meter, leading edge of curtain 2x / week for 23 days Time to contamination survival analysis 234 curtains sampled
1. Schweizer ML et al. Infect Control Hosp Epidemiol 2012 (33)11: 1081-85 FOR MORE INFO... Time to Contamination 1. Schweizer ML et al. Infect Control Hosp Epidemiol 2012 (33)11: 1081-85 FOR MORE INFO... Antimicrobial Privacy Curtains Longer median time to contamination (14 days vs 2 days, p<0.01)
Sub-analyses 8 standard vs 1 CEC curtain were VRE+, unadjusted relative risk [RR], 8.0; p<0.01) 29% lower contamination with CEC curtain, adjusted* RR, 0.71; 95% CI, 0.481.07
Adjusted for ICU type (MICU vs SICU), # beds per room Self-disinfecting Surfaces Suboptimal cleaning of surfaces <50% cleaned ~75% with education and feedback UV and vaporized hydrogen peroxide Restricted to terminal cleaning Costs Increased turnover time
Weber DJ and Rutala WA et al. Am J Infect Control 2013(41)S31-35 FOR MORE INFO... Self-disinfecting Technologies Weber DJ and Rutala WA et al. Am J Infect Control 2013(41)S31-35 FOR MORE INFO... Costs, benefits and data? Weber DJ and Rutala WA et al. Am J Infect Control 2013(41)S31-35 FOR MORE INFO... Advantages Continuous disinfection without effort Broad-spectrum, low toxicity Disadvantages Cant coat all surfaces, durability Efficacy in reducing HAI has not been demonstrated in clinical trials Cost and Resistance Copper Copper Surfaces in ICU: An RCT ICUs in 3 US Hospitals Screen for MRSA at three facilities VRE screening at 2 hospitals
Primary outcome: Incident rate of HAI and/or MRSA or VRE colonization
8 copper vs 8 control rooms
Salgado CD et al. Infect Control Hosp Epidemiol. 2013:34(5):479-486 FOR MORE INFO... 6 Surfaces Treated All ICUs had these four: Bed rails, overbed tables, IV poles, arms of visitor chairs
Additional two: Nurses call button, computer mouse, bezel of touchscreen monitor, palm rest of laptop computer
Salgado CD et al. Infect Control Hosp Epidemiol. 2013:34(5):479-486 FOR MORE INFO... Exposure 614 patients randomized
Copper exposed patients: 47% had all days with 6 copper surfaces treated
Controls: 13% exposed to copper Salgado CD et al. Infect Control Hosp Epidemiol. 2013:34(5):479-486 FOR MORE INFO... Outcomes 46 developed an HAI (7.5%)
26 became colonized with MRSA or VRE
Primary outcome HAI and/or VRE/MRSA colonization 0.071 vs 0.128. p=0.013 (45% reduction) Salgado CD et al. Infect Control Hosp Epidemiol. 2013:34(5):479-486 FOR MORE INFO... Concerns http://haicontroversies.blogspot.com/2013/04/the-environment-and-hai-where-does_25.html FOR MORE INFO... Complex system of outcomes SINGLE Outcomes (a) any episode HAIs (b) colonization with MRSA or VRE COMPOSITE outcomes (c) both HAI and colonization (both) (d) HAI and/or colonization (either)** (e) HAI only but no colonization (# of patients who had HAI minus the ones who had both HAI & colonization)** (f) colonization only but no HAI** ** Salgado et al only reported d-f Harbarth et al. Infect Control Hosp Epidemiol (letter) 2013;34(9):996-997 FOR MORE INFO... Harbarth et al. Infect Control Hosp Epidemiol (letter) 2013;34(9):996-997 FOR MORE INFO... Criticisms Selectively not reporting primary outcomes (a) and (b)
MRSA/VRE colonization acquisition was not defined; one site didnt collect VRE data
Most HAI reduction was BSI (3 vs 11) but no data on CVC-related vs secondary and no denominator data (1,000 CVC days)
Harbarth et al. Infect Control Hosp Epidemiol (letter) 2013;34(9):996-997 FOR MORE INFO... Biological Plausibility? How can suboptimal placement of copper on 6 surfaces reduce HAI by 50%? Only 10% of surfaces were coated And 13% controls exposed to copper
50% reduction is beyond our current understanding of endogenous sources being primary Harbarth et al. Infect Control Hosp Epidemiol (letter) 2013;34(9):996-997 FOR MORE INFO... Conclusion The importance of the environment in nosocomial transmission is not disputed Antimicrobial textiles and coated surfaces have the theoretical potential to limit the environmental burden and prevent infection Data in hospital settings is sorely lacking